Get the free EMP ENR-0913-090315COBRA Continuation Coverage Election Form

Print Form 700 Bishop Street, Suite 300 Honolulu, HI 96813.4100 T 808.532.4007 F 877.222.3198 www.uhahealth.com COBRA CONTINUATION COVERAGE ELECTION FORM SECTION 1 Notification (To be completed by

How to fill out emp enr-0913-090315cobra continuation coverage

How to fill out emp enr-0913-090315cobra continuation coverage:

1. Obtain the emp enr-0913-090315cobra continuation coverage form from your employer or the relevant insurance provider. This form is typically provided when an individual experiences a qualifying event that makes them eligible for COBRA coverage.
2. Start by entering your personal information in the designated fields. This usually includes your name, address, social security number, and contact information.
3. Next, provide details about the qualifying event that makes you eligible for COBRA continuation coverage. This can include voluntary or involuntary employment termination, reduction in work hours, or certain life events such as divorce or death of the covered employee.
4. Indicate whether you are the employee or the qualified beneficiary who is electing COBRA coverage. If you are a qualified beneficiary, specify your relationship to the employee (e.g., spouse, dependent child).
5. If you are electing COBRA coverage for dependents, provide their names and other relevant information in the appropriate sections.
6. Determine the coverage start date and choose the duration of your COBRA coverage. This period can range from 18 to 36 months, depending on the qualifying event.
7. Calculate and enter the applicable premium for the COBRA continuation coverage. This is typically a higher amount than what was previously paid while actively employed.
8. Sign and date the form, certifying that the information provided is accurate and complete.
9. Submit the completed emp enr-0913-090315cobra continuation coverage form to your employer or the designated entity responsible for administering COBRA coverage.

Who needs emp enr-0913-090315cobra continuation coverage?

1. Individuals who experience a qualifying event that results in the loss of their employer-sponsored health insurance may need COBRA continuation coverage. This can include employees who have been terminated or had their work hours reduced, as well as their eligible dependents.
2. Spouses and dependent children of covered employees who lose their health insurance due to divorce or the death of the covered employee may also require COBRA continuation coverage.
3. It is important to note that COBRA continuation coverage is typically an option for those who were previously enrolled in their employer's health insurance plan.

For pdfFiller’s FAQs

What is emp enr-0913-090315cobra continuation coverage?

emp enr-0913-090315cobra continuation coverage is a form that allows employees and their qualified beneficiaries to continue health insurance coverage after a qualifying event.

Who is required to file emp enr-0913-090315cobra continuation coverage?

Employers with 20 or more employees who offer group health insurance coverage are required to provide emp enr-0913-090315cobra continuation coverage.

How to fill out emp enr-0913-090315cobra continuation coverage?

Employers can fill out emp enr-0913-090315cobra continuation coverage by providing information about the qualifying event, the individuals eligible for continuation coverage, and the cost of coverage.

What is the purpose of emp enr-0913-090315cobra continuation coverage?

The purpose of emp enr-0913-090315cobra continuation coverage is to provide temporary health insurance coverage to employees and their qualified beneficiaries after certain life events.

What information must be reported on emp enr-0913-090315cobra continuation coverage?

Information required on emp enr-0913-090315cobra continuation coverage includes details about the plan, the qualifying event, the individuals eligible for coverage, and the cost of coverage.

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