Get Continuation Of Coverage Under Cobra Or State Group

This guide provides step-by-step instructions on how to accurately fill out the continuation of coverage under COBRA or state group form online. By following these instructions, users can ensure they complete the form correctly and efficiently.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to acquire the form and open it in your preferred editor.
2. Begin by filling out the employer information section. Provide the name of the group, group policy number, and the complete address including city, state, and ZIP code.
3. Next, indicate the reason(s) for group coverage ending by selecting the appropriate option(s) from the list provided.
4. Fill in the details of the continuing employee, spouse, or child. This includes their name, social security number, relationship to the employee, and date of birth.
5. Input the name of the employee whose coverage has ended and their last covered date. Be sure to provide the employee's address, city, state, and ZIP code.
6. If applicable, provide the date of the employee's death and decide whether to waive the right for COBRA continuation of coverage by checking the appropriate box.
7. Finally, ensure that both the employee/dependent(s) and employer sign and date the form in the designated areas.
8. Once all sections are completed, save your changes, and decide whether to download, print, or share the form as needed.

Complete your forms online today and secure your coverage!