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Get CA PERS-HBD-85 2019-2024

ONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA) PERS-HBD-85 (Rev 05/19) INSTRUCTIONS FOR COMPLETING THIS FORM ARE ON THE REVERSE SIDE. PLEASE TYPE PART A: TYPE OF ACTION AND DATES 1.Type of Action NEW CHANGE CANCEL 2. TYPE OF PERMITTING EVENT . EMPLOYMENT SEPARATION/TIME BASE REDUCTION 3. EVENT DATE DIVORCE/LEGAL SEPARATION CHILD CEASES TO BE A DEPENDENT DEATH OF AN EMPLOYEE/RETIREE DEPENDENT ELIGIBILITY VERIFICATION DEPENDENT CONTINUATION-ORIGINAL ENROLLEE ELIGIBLE FOR MEDICARE SSA C.

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