Get the free COBRA Continuation Form

Application for Continuation of Group Dental Coverage (COBRA) With the passage of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), most employer sponsored group health plans are

How to fill out cobra continuation form

1. To fill out the Cobra continuation form, start by obtaining the form from your employer or insurance provider.
2. Begin by providing your personal information, including your full name, address, and contact details.
3. Next, you will need to provide specific details about your previous health insurance coverage, such as the name of the insurance company and the policy number.
4. Indicate the reason for the loss of coverage, whether it was due to termination, resignation, or another circumstance.
5. Specify the date on which your previous health insurance coverage ended.
6. You will also need to provide the names of any dependents who were covered under the previous health insurance plan. Include their full names and other relevant information.
7. If you are electing the Cobra continuation coverage, indicate the duration you want the coverage to be in effect for.
8. Proceed by signing and dating the form to certify the accuracy of the provided information.
9. Keep a copy of the completed form for your records and submit the original form to your employer or insurance provider as directed.

Who needs the Cobra continuation form?

1. Individuals who have recently experienced a loss of health insurance coverage, either due to termination, resignation, or another qualifying event, may need to fill out the Cobra continuation form.
2. The Cobra continuation form is typically required by employees who were covered under an employer-sponsored health insurance plan and wish to continue their coverage at their own expense after their employment ends.
3. Additionally, dependents of employees who were covered under the employer-sponsored health insurance plan may also need to complete the Cobra continuation form to continue their coverage.

For pdfFiller’s FAQs

What is cobra continuation form?

COBRA continuation form is a form that allows employees to continue their health insurance coverage after leaving their job or experiencing a qualifying event.

Who is required to file cobra continuation form?

Employers are required to provide the COBRA continuation form to employees who are eligible for continuation coverage.

How to fill out cobra continuation form?

To fill out the COBRA continuation form, employees must provide their personal information, the reason for their eligibility for continuation coverage, and select the coverage options.

What is the purpose of cobra continuation form?

The purpose of the COBRA continuation form is to allow employees to continue their health insurance coverage for a limited period after leaving their job or experiencing a qualifying event.

What information must be reported on cobra continuation form?

The COBRA continuation form must include the employee's personal information, the reason for their eligibility for continuation coverage, and the coverage options chosen.

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