Get Cs-613-7-04. Cs-613-7-04 - Archlou

Filling out the CS-613-7-04 form is an essential step in managing COBRA continuation coverage. This guide provides clear, step-by-step instructions to help users complete the form accurately, ensuring that their information is processed without delays.

Follow the steps to fill out the CS-613-7-04 form online.

1. Use the ‘Get Form’ button to access the CS-613-7-04 form and open it in your chosen editor.
2. Identify the COBRA qualifying event that caused the loss of coverage by checking the appropriate box in section 16. Make sure to select only one option from the listed choices.
3. In section 1a, enter the name of the company associated with the qualifying event. Provide the division or region code in section 1b and the company ID or unit code in section 1c if applicable.
4. Enter the Ceridian COBRA Services account number in section 2 to ensure your request is linked to the correct account.
5. In section 3, indicate whether the qualifying event applies to the employee or a dependent by checking the corresponding box.
6. Provide the social security number of the qualified beneficiary in section 4. Ensure accuracy to avoid processing issues.
7. Fill out section 17, supplying the necessary information for the spouse and any dependents. Include names, social security numbers, and dates of birth.
8. Complete the additional fields for the qualified beneficiary’s address and contact information in sections 5 and 6, ensuring clarity and correctness.
9. In section 15, refer to your Client Rate Report and enter the current carrier option, option code, and plan code for each coverage in effect at the time of the qualifying event.
10. Review all filled-out sections for accuracy. After completing the form, you can save changes and choose to download, print, or share the document as needed.

Submit your completed CS-613-7-04 form online to get started with your COBRA coverage.