Get Cobra Administrative Services Acceptance Form As The Authorized Representative* For , (company

The COBRA Administrative Services Acceptance Form is a critical document for authorized representatives of a company to engage in administrative services related to COBRA health benefits. This guide provides a step-by-step approach to accurately completing the form online, ensuring compliance with legal requirements.

Follow the steps to successfully complete the COBRA acceptance form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. In the designated space, enter the company name for which you are acting as an authorized representative.
3. Request an effective date for the administrative services by filling in the month, day, and year in the appropriate section.
4. Affirm your understanding that the services are governed by the terms outlined in the COBRA administrative services agreement. You can review this agreement at the provided link.
5. Sign the form in the space provided for the authorized representative's signature.
6. Include the date on which you are signing the form.
7. Print your name clearly in the section for the printed name of the authorized representative.
8. Indicate your job title in the corresponding section.
9. Provide a telephone number where you can be reached.
10. Enter your email address in the designated field.
11. Fill in the group number that applies to your company.
12. After completing all sections, fax the completed form to Providence Health Plan at 503-574-7543.

Complete your COBRA Administrative Services Acceptance Form online today!