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Get CA PERS-HBD-85 2018

CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT "COBRA" PERS-HBD-85 (Rev 04/18) INSTRUCTIONS FOR COMPLETING THIS FORM ARE ON THE REVERSE SIDE. PLEASE TYPE PART A: ORIGINAL QUALIFYING EVENT AND DATES 1. Type of Action NEW CHANGE 3. EVENT DATE 2. QUALIFYING EVENT EMPLOYMENT SEPARATION TIME BASE REDUCTION DIVORCE/LEGAL SEPARATION CHILD CEASES TO BE A DEPENDENT DEATH OF AN EMPLOYEE/RETIREE DEPENDENT ELIGIBILITY VERIFICATION DEPENDENT CONTINUATION-ORIGINAL ENROLLEE ELIGIBLE FOR MEDICARE 4. COBR.

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