Get Cal-cobra Enrollment Request Form - Mhn

This guide provides users with clear and detailed instructions on how to accurately complete the Cal-Cobra Enrollment Request Form - MHN online. By following these steps, you can ensure a smooth enrollment process for your Cal-COBRA benefits.

Follow the steps to successfully fill out the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section, enter your name in the format of last, first, and middle initial. This ensures proper identification for your enrollment process.
3. If you have a current member ID number, please include it in the designated field. If not, you may leave this section blank.
4. Provide the name of your former employer in the corresponding area. This information is necessary to verify your previous coverage.
5. Fill in your current address in the space provided. This address will be used for any correspondence regarding your benefits.
6. Enter your date of birth in the specified field. This is required for identification purposes.
7. List the names and dates of birth of any dependents you wish to include. You may provide up to five dependents. Ensure that all names are complete and accurate.
8. Once you have completed the form, sign and date it at the end to confirm that the information provided is accurate and complete.
9. After finalizing your entries, you can save changes, download, print, or share the form as needed for your records.

Start filling out your Cal-Cobra Enrollment Request Form - MHN online today!