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CONTINUATION COVERAGE RIGHTS UNDER COBRA I have read and understand the information regarding the continuation coverage rights under COBRA. Employee Name (Please Print) Rev 04/2012 * Banner/ECO ID

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What is cobra acknowledgement form?

The COBRA acknowledgement form is a document that employees receive when they become eligible for continuing health insurance coverage through the Consolidated Omnibus Budget Reconciliation Act (COBRA). It serves as confirmation of their understanding of their rights and obligations.

Who is required to file cobra acknowledgement form?

Employees who become eligible for COBRA coverage are required to file the COBRA acknowledgement form. This includes employees who have experienced a qualifying event that results in a loss of health insurance coverage.

How to fill out cobra acknowledgement form?

To fill out the COBRA acknowledgement form, employees should carefully read the instructions provided and provide accurate information. They may need to provide personal details, such as their name, address, and contact information, as well as details about their previous health insurance coverage and qualifying event.

What is the purpose of cobra acknowledgement form?

The purpose of the COBRA acknowledgement form is to ensure that eligible employees are aware of their rights and responsibilities under COBRA. It also serves as documentation that they have received the necessary information about continuing health insurance coverage.

What information must be reported on cobra acknowledgement form?

The COBRA acknowledgement form typically requires information such as the employee's personal details (name, address, contact information), details about their previous health insurance coverage, and information about the qualifying event that resulted in their loss of coverage.

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