Get Connecticut Continuation Coverage Election Notice - Ct.gov

This guide provides clear instructions on how to complete the Connecticut Continuation Coverage Election Notice. It is designed to support individuals in understanding their options for continuing health care coverage following qualifying events.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Connecticut Continuation Coverage Election Notice form. This will allow you to open it in your selected editing tool.
2. Begin by filling in the 'Date of Notice' field with the current date. In the following field, write the name of the qualified beneficiary or beneficiaries who will be affected by the continuation coverage.
3. In the section that describes the reason for receiving the notice, indicate the specific reason for the coverage ending, such as end of employment or loss of dependent child status.
4. Next, review the list of qualified beneficiaries and check the appropriate boxes for each individual who is eligible for continuation coverage.
5. Fill out the section detailing the qualifying event by checking the corresponding boxes based on the circumstances of coverage loss.
6. In the 'Continuation Coverage Election Form' section, specify which coverage option you are electing by naming the plan and indicating your relationship to each individual listed.
7. Provide any necessary personal information, including signatures and dates, in the designated areas of the form.
8. Finally, review all the information entered for accuracy. Save your changes, then download, print, or share the completed form as required.

Take action today by completing your Connecticut Continuation Coverage Election Notice online.