Get Cobra Addition Of A Dependent Form

Understanding how to properly fill out the COBRA Addition Of A Dependent Form is essential for ensuring your dependents are added to your coverage. This guide provides a clear and supportive overview of each section of the form to help users complete it efficiently online.

Follow the steps to complete the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with entering your Primary Qualified Beneficiary Information. Fill in your name, Social Security Number, the name of your employer sponsoring the benefits (do not abbreviate), your daytime telephone number, and your email address. All fields marked with an asterisk are required.
3. Next, proceed to the Dependent Information section. Select the reason for adding dependents, which may include marriage, birth, adoption, or loss of coverage. Depending on your reason, you may need to attach additional documentation such as a marriage certificate or birth certificate. Remember, this form must be submitted within 30 days of the qualifying event.
4. In Step 2a, provide the Spouse Information. Fill in your spouse's name, date of birth, Social Security Number, and gender. Then, indicate which plans to add the spouse to, such as medical, dental, or vision.
5. In Step 2b, fill in the Child(ren) Information. Repeat the same process for each child by entering their name, date of birth, Social Security Number, and gender. Again, select applicable plans for each child.
6. Complete Step 3: Primary Qualified Beneficiary Certification. Review the statement provided, then sign and date the form to certify your request to add dependents.
7. Once all sections have been completed, make sure to save any changes. You can then download, print, or share the form according to your needs.

Start filling out your COBRA Addition Of A Dependent Form online today!