Get Cobra/alternative Coverage Form (see ... - Selecthealth - Selecthealth

Filling out the COBRA/ALTERNATIVE COVERAGE Form is an essential process for ensuring continued health coverage. This guide provides clear instructions for completing each section of the form accurately, helping you navigate the necessary steps smoothly.

Follow the steps to complete your COBRA/ALTERNATIVE COVERAGE Form

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section A, provide your information as the qualified beneficiary. Include your name, social security number, address, phone numbers, and marital status. If you are not the employee, also provide the employee's details.
3. In Section B, list all individuals you wish to cover, including yourself and any eligible dependents, in the order of age. Clearly indicate each individual's relationship to you.
4. If applicable, answer the questions regarding your ex-spouse's responsibilities for dependent medical expenses and whether you have other health insurance. Provide details as requested.
5. Section C requires your signature as a qualified beneficiary. Carefully read the terms before signing and dating the form.
6. In Section D, ensure the employer representative completes the required information regarding the qualifying event and coverage period.
7. Review the entire form for accuracy and completeness. Ensure all required fields are legibly filled out.
8. Once all sections are complete, you can save your changes, download, print, or share the form as needed.

Start filling out your COBRA/ALTERNATIVE COVERAGE Form online today for continued health coverage.