Get Wageworks Cobra Appeal Form 2013-2025

Filing an appeal for COBRA coverage termination can feel overwhelming, but by following the proper steps to complete the WageWorks COBRA Appeal Form, you can ensure your appeal is submitted correctly. This guide provides clear and supportive instructions to help you navigate the form with ease.

Follow the steps to fill out the WageWorks COBRA Appeal Form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the participant information. Provide your name, former employer, participant ID number, email address, mailing address, city, state, zip code, and telephone number. This is critical for identifying your appeal.
3. In the appeal information section, indicate the COBRA termination date and the reason for termination. Clearly state your reason for appeal in the designated field.
4. Specify who is filing the appeal by selecting from the options: self, spouse, child, or other. Include names of any dependents involved in the appeal.
5. Under payments and correspondence, list all payments made for COBRA coverage along with their corresponding dates and amounts. Document all letters received regarding COBRA coverage, noting their dates and subjects.
6. Include any additional information relevant to the COBRA termination and your appeal. This can include supporting comments, documents, or records.
7. Finally, sign and date the form. Ensure that your signature is clearly recorded.
8. Once you have completed the form, save the changes, then download or print it for submission. You can now mail or fax the completed form along with any additional documentation to WageWorks, Inc. at the provided address.

Complete the WageWorks COBRA Appeal Form online today to ensure your appeal is submitted promptly.