Get Kaiser Cobra Form - Filice

Completing the Kaiser COBRA Form - Filice online is a straightforward process that enables you to manage your Cal-COBRA enrollment efficiently. This guide provides step-by-step instructions to assist you through each component of the form.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the employer group coverage information, including the Purchaser/Enrollment Unit Number provided by your employer. Ensure to include the employer's name, your name (last, first, middle initial), and your medical record number as printed on your ID card.
3. Indicate your date of birth and confirm whether Kaiser Permanente was your group coverage during employment by selecting the appropriate option.
4. Select the reason for your Cal-COBRA enrollment by checking the corresponding box. Provide the last date of group coverage or the effective date of loss as prompted for each selection.
5. Complete the additional enrollment information section if applicable, including details about any disabilities or health care tax credits for which you are applying.
6. List all members to be enrolled in the account under the subscriber and family information section. Input names, Social Security numbers, dates of birth, gender, and medical record numbers for each family member.
7. Review your entries for correctness and completeness. Be sure that the subscriber (employee) signs and dates the form at the end. If applicable, signatures from dependents or legal guardians may also be required.
8. Once finalized, save your changes. You may then download, print, or share the form as needed, and ensure you retain a copy for your records.

Complete your forms online and take control of your COBRA enrollment today.