Get Az Cobra Enrollment Form - City Of Mesa 2016-2025

Completing the AZ COBRA Enrollment Form is essential for securing your health coverage continuation through the City of Mesa. This guide will provide you with clear, step-by-step instructions to assist you in accurately filling out the form online.

Follow the steps to complete your enrollment form online.

1. Click 'Get Form' button to obtain the AZ COBRA Enrollment Form and open it for editing.
2. Begin by filling out the employer section. Indicate whether you are changing your COBRA coverage (adding or dropping) or if you are applying for a new COBRA enrollment. Specify the effective date for COBRA coverage.
3. In the COBRA participant information section, enter the participant's last name, first name, and middle initial. Include the home address, phone number, employee ID number, and date of birth. Also, provide the gender and social security number.
4. If applicable, fill in the name and employee ID number of the employee or retiree under whom coverage was previously held. Include their work phone number.
5. Select the marital status from the options provided: single, widowed, married, or divorced.
6. Choose your medical/prescription drug coverage option. You can elect to keep your current plan or opt out. Indicate whether you need coverage for yourself, dependent(s), or both.
7. For dental coverage, repeat the selection process by choosing whether to keep the current dental plan or opt out.
8. Indicate your vision coverage by selecting the appropriate plan election. As with medical and dental, you may choose to keep your current plan or opt out.
9. For the flexible spending account (health) election, indicate your choice, selecting whether you want to keep your current election or opt out.
10. List any dependents who will continue coverage. Include their names, relationships, genders, dates of birth, and social security numbers. Select the type of coverage they will require using the options provided.
11. Read through the agreement and signature section, confirming your understanding of payment obligations and coverage terms. Provide your signature and date to finalize your application.
12. After completing all sections of the form, review your entries for accuracy. You can then save changes, download, print, or share the completed form as needed.

Take action to ensure your health coverage by completing the AZ COBRA Enrollment Form online today.