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This form is required for retirees to continue their Medical Expense Reimbursement Plan (MERP) coverage for the plan year 2012. It includes options for coverage for self or self plus one, as well

How to fill out continuation of coverage form

How to fill out Continuation of Coverage Form

1. Obtain the Continuation of Coverage Form from your employer or plan administrator.
2. Read the instructions carefully to understand the information required.
3. Fill out your personal information, including your full name, address, and contact details.
4. Indicate the qualifying event that gave rise to the need for continuation coverage.
5. Specify the dates of your coverage under the previous health plan.
6. Provide any additional information requested, such as dependent information if you're enrolling family members.
7. Review your entries to ensure accuracy and completeness.
8. Sign and date the form where indicated.
9. Submit the completed form to the appropriate contact as stated in the instructions, ensuring to keep a copy for your records.

Who needs Continuation of Coverage Form?

1. Individuals who have recently experienced a qualifying event such as job loss, reduction in work hours, divorce, or death of a covered employee.
2. Dependents of covered employees who wish to continue coverage after the qualifying event.

People Also Ask about

What is the COBRA continuation coverage election form?

As a participant whose coverage terminated due to a qualifying event, you have the right to elect continuation of your Covered California group health coverage. through COBRA. To elect COBRA continuation coverage, complete this Election Form and return it to your former employer.

What does continuation of coverage mean?

Continuation coverage allows someone who recently lost their employer-based health coverage to continue their current insurance policy as long as they pay the full monthly premiums. Continuation coverage falls into four categories: COBRA, Cal-COBRA, Conversion, and HIPAA.

Can I get COBRA coverage retroactively?

If you are currently receiving COBRA coverage for which a premium is being paid and you wish to waive future coverage, you can simply refrain from paying the COBRA premium for that coverage period.

How long can my spouse stay on COBRA if I go on Medicare?

COBRA coverage is retroactive to the day after the original health insurance ended, as long as the election is made and any required premiums are paid. It continues without interruption, keeping the same benefits and terms as the original plan.

How long is temporary continuation of coverage?

Separating employees can continue TCC for up to 18 months after the date of separation. Children and former spouses can continue TCC for up to 36 months after: the date of the qualifying event when the child or former spouse is covered as a family member of an employee or annuitant under a regular FEHB enrollment, or.

What is the 60 day rule for COBRA?

You have 60 days after being notified to sign up. If you are eligible for Federal COBRA and did not get a notice, contact your employer. If you are eligible for Cal-COBRA and did not get a notice, contact your health plan. If you miss the deadline, you may lose the chance to sign up for Federal COBRA or Cal-COBRA.

What is the 60 day loophole for cobras?

You have 60 days to enroll in COBRA once your employer-sponsored benefits end. Even if your enrollment is delayed, you will be covered by COBRA starting the day your prior coverage ended.

For pdfFiller’s FAQs

What is Continuation of Coverage Form?

The Continuation of Coverage Form is a document used to allow individuals to continue their health insurance coverage after a triggering event, such as job loss or other qualifying events.

Who is required to file Continuation of Coverage Form?

Employers sponsoring group health plans are required to provide the Continuation of Coverage Form to eligible employees and their dependents when a qualifying event occurs.

How to fill out Continuation of Coverage Form?

To fill out the Continuation of Coverage Form, individuals need to provide personal information, details about the qualifying event, and select the coverage options they wish to continue, along with their signature and date.

What is the purpose of Continuation of Coverage Form?

The purpose of the Continuation of Coverage Form is to ensure that individuals maintain their health insurance coverage without interruption after facing certain life changes, thereby protecting their access to healthcare.

What information must be reported on Continuation of Coverage Form?

The information that must be reported on the Continuation of Coverage Form includes the insured person's name, address, date of birth, details of the qualifying event, and the type of coverage being continued.