Get the free Cal-Cobra Enrollment Request Form

Please complete and mail this form to begin the enrollment process for your Cal-COBRA benefits.

How to fill out cal-cobra enrollment request form

How to fill out Cal-Cobra Enrollment Request Form

1. Obtain the Cal-Cobra Enrollment Request Form from your employer or insurance provider.
2. Fill in your personal information including your name, address, and Social Security number.
3. Provide details about your previous health insurance coverage, including the policy number.
4. Specify the reason for your Cal-Cobra enrollment, such as job loss or reduction in work hours.
5. Indicate the desired coverage period for Cal-Cobra.
6. Sign and date the form to certify that the information is accurate.
7. Submit the completed form to your employer or insurance provider as instructed.

Who needs Cal-Cobra Enrollment Request Form?

1. Individuals who have recently lost group health coverage due to job loss or reduced work hours.
2. Employees or dependents of an employer that provides Cal-Cobra options.
3. Individuals who want to maintain continuous health coverage after qualifying events.

People Also Ask about

Who sends out COBRA paperwork?

A notice sent to the spouse is treated as a notification to all qualified dependent children residing with the spouse at the time the spouse's notification is sent by the plan administrator. Notices must be provided in person or by first class mail.

What is the difference between COBRA and cal-COBRA?

Federal COBRA generally extends health coverage for 18 months. Individuals with certain qualifying events may be eligible for a longer extension (e.g., 29 or 36 months). Cal-COBRA allows individuals to continue their group health coverage for up to 36 months.

Who sends Cal-COBRA notices?

When employees or dependents experience a qualifying event, employers must provide an election notice within 14 days of the notice of the qualifying event, notifying them of their eligibility to enroll in Cal-COBRA coverage, the terms and amount of the premium payment, and the beginning and ending dates of coverage.

Who sends Cal-COBRA paperwork?

The HR office must provide the COBRA Election Notice and Election Form to qualified beneficiaries within 14 days from the date of the qualifying event or loss of coverage, or when the HR office is notified, whichever comes first.

For pdfFiller’s FAQs

What is Cal-Cobra Enrollment Request Form?

The Cal-Cobra Enrollment Request Form is a document used by individuals to enroll in the Cal-Cobra continuation of coverage program, allowing them to extend their health insurance coverage after certain qualifying events.

Who is required to file Cal-Cobra Enrollment Request Form?

Individuals who have lost their group health insurance coverage due to specific qualifying events, such as job loss, reduced work hours, or other qualifying circumstances, are required to file the Cal-Cobra Enrollment Request Form.

How to fill out Cal-Cobra Enrollment Request Form?

To fill out the Cal-Cobra Enrollment Request Form, individuals must provide personal information, including name, address, date of birth, and details about their previous health insurance coverage, and submit it to their health plan for processing.

What is the purpose of Cal-Cobra Enrollment Request Form?

The purpose of the Cal-Cobra Enrollment Request Form is to provide a formal process for eligible individuals to request continuation of their health insurance coverage under the Cal-Cobra program.

What information must be reported on Cal-Cobra Enrollment Request Form?

The Cal-Cobra Enrollment Request Form typically requires personal demographic information, prior health insurance details, qualifying event information, and a signature for authorization.