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Safeguard Health Plans, Inc. Telehealth Life Insurance Company Federal COBRA/Calibra Election Enrollment Form The California Continuation Benefits Replacement Act, or Calibra, requires Employers with

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How to fill out cal-cobra 11687 1-04p65

How to fill out cal-cobra 11687 1-04p65?

01

Begin by gathering all the necessary information and documents needed to complete the form.

02

Start by entering the date in the designated space on the form.

03

Provide your name, address, and contact information in the corresponding fields.

04

Indicate whether you are the primary subscriber or the qualified beneficiary.

05

Mention the reason for the COBRA continuation coverage and the name of the previous group health plan.

06

Specify the date on which the previous coverage ended and the reason for the termination.

07

Enter the name and contact information of the employer or plan administrator.

08

Provide details about the qualified beneficiary, including their name, address, and relationship to the primary subscriber.

09

Indicate the type of continuation coverage being elected and the specific coverage periods.

10

Sign and date the form to verify the accuracy of the information provided.

Who needs cal-cobra 11687 1-04p65?

01

Individuals who were covered under a group health plan and are now eligible for COBRA continuation coverage may need to fill out cal-cobra 11687 1-04p65.

02

Qualified beneficiaries, such as employees who have been terminated from their jobs, may need to complete this form to continue their health coverage.

03

Dependents of qualified beneficiaries who have lost coverage due to certain events, such as divorce or the death of the primary subscriber, may also need to fill out this form.

It is essential to consult with the specific employer or plan administrator to determine the requirement of cal-cobra 11687 1-04p65 and to ensure accurate and timely completion of the form.

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What is cal-cobra 11687 1-04p65?

cal-cobra 11687 1-04p65 is a form used for reporting COBRA continuation coverage.

Who is required to file cal-cobra 11687 1-04p65?

Employers who provide COBRA continuation coverage are required to file cal-cobra 11687 1-04p65.

How to fill out cal-cobra 11687 1-04p65?

cal-cobra 11687 1-04p65 should be filled out with information about the COBRA coverage provided, including details about the covered individual and the duration of coverage.

What is the purpose of cal-cobra 11687 1-04p65?

The purpose of cal-cobra 11687 1-04p65 is to report information about COBRA continuation coverage to the IRS.

What information must be reported on cal-cobra 11687 1-04p65?

cal-cobra 11687 1-04p65 must include details such as the covered individual's name, social security number, and the duration of COBRA coverage.

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