Get the free COBRA Election Form - ACWAJPIA

COBRA Election Form Fax to (916) 3252598 or Email password protected to benefits acwajpia.com PO Box 619082 Roseville CA 95661 (800) 7362292 Employer: Location #: Effective Date: Qualifying Event

How to fill out cobra election form

How to Fill Out COBRA Election Form:

Obtain the COBRA Election Form:

1. Contact your former employer's benefits department or the COBRA administrator to request the form.
2. You can also find the form online on the Department of Labor's website or from a reputable benefits administration website.

Provide Personal Information:

1. Fill in your full name, address, and contact information in the designated fields.
2. Include your Social Security number and the names of any covered dependents, if applicable.

Date of Qualifying Event:

1. Indicate the date of the qualifying event that makes you eligible for COBRA coverage (e.g., termination of employment, reduction in hours).
2. This date is crucial as it determines your eligibility period for COBRA continuation coverage.

Select Coverage Options:

1. Choose the type of COBRA coverage you wish to elect (e.g., medical, dental, vision).
2. If you have eligible dependents, indicate whether you want to include them in your coverage.

Calculate and Enter Premium Payments:

1. Determine the premium amount for the COBRA coverage you selected.
2. This typically involves multiplying the total cost of the plan by the percentage you're required to pay under COBRA regulations.
3. Enter the calculated premium amount on the form.

Review and Sign:

1. Carefully review the information provided to ensure accuracy.
2. Sign and date the form to confirm your election for COBRA coverage.
3. If you have eligible dependents, they will also need to sign and date the form.

Who Needs COBRA Election Form:

Employees who have recently experienced a qualifying event:

1. Individuals who have been terminated from employment or had their work hours reduced.
2. If your former employer had 20 or more employees, you may be eligible for COBRA.

Dependents of eligible employees:

1. Spouses, children, and other dependents who were covered under the employee's group health insurance plan.
2. They may be eligible for COBRA continuation coverage even if the employee is not.
3. Individuals who lost their coverage due to a qualifying event, such as divorce, dependency age limit, or death of the employee.

Remember, it's essential to submit your COBRA election form within the specified time frame to ensure the continuation of health insurance coverage for you and your eligible dependents.

For pdfFiller’s FAQs

What is cobra election form?

The cobra election form is a document that allows individuals to elect to continue their health insurance coverage under COBRA (Consolidated Omnibus Budget Reconciliation Act) after experiencing a qualifying event.

Who is required to file cobra election form?

Individuals who experience a qualifying event that causes them to lose their employer-sponsored health insurance coverage are required to file a cobra election form.

How to fill out cobra election form?

To fill out a cobra election form, individuals must provide personal information, details of the qualifying event, and elect to continue their health insurance coverage under COBRA.

What is the purpose of cobra election form?

The purpose of the cobra election form is to give individuals the option to continue their health insurance coverage under COBRA in situations where they would otherwise lose coverage.

What information must be reported on cobra election form?

The cobra election form requires individuals to report personal information, details of the qualifying event, and their decision to elect COBRA coverage.

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