Get the free CONTINUATION OF COVERAGE ELECTION FORM

Massachusetts Business Association CONTINUATION OF COVERAGE ELECTION FORM Employee Name Address Subscriber ID # Social Security # (if different) Name of Former Employer Group: Name of Spouse and×or

How to fill out continuation of coverage election

How to fill out continuation of coverage election:

1. Obtain the continuation of coverage election form from your employer or the insurance company. This form may also be available online.
2. Fill in your personal information, including your full name, address, contact information, and social security number. Make sure all the information is accurate and up-to-date.
3. Indicate the coverage you wish to continue by checking the appropriate box. This could include medical, dental, vision, or other types of insurance.
4. Provide the reason for the continuation of coverage election. This is typically due to a qualifying event such as job loss, divorce, or the death of the primary insured individual.
5. If applicable, provide information about any dependents you want to continue coverage for. This may include their names, social security numbers, and relationship to you.
6. Review the form carefully and ensure all required fields are completed. Check for any errors or missing information.
7. Sign and date the form to indicate your agreement and understanding of the continuation of coverage terms. Some forms may require notarization, so be sure to follow the instructions provided.
8. Keep a copy of the completed form for your records before submitting it to the appropriate party, such as your employer or the insurance company.

Who needs continuation of coverage election:

1. Individuals who have experienced a qualifying event that results in the loss of their previous insurance coverage may need to elect continuation of coverage.
2. This can include individuals who have been terminated from their jobs, divorced or legally separated, or have lost coverage due to the death of the primary insured person.
3. Dependents of the primary insured individual may also be eligible for continuation of coverage if they were covered under the previous insurance policy.
4. In some cases, individuals who no longer qualify as dependents under the previous insurance plan but still need coverage may also elect continuation of coverage.

For pdfFiller’s FAQs

What is continuation of coverage election?

Continuation of coverage election allows an individual to continue their existing health insurance coverage even after a qualifying event has occurred, such as losing a job or getting divorced.

Who is required to file continuation of coverage election?

Individuals who experience a qualifying event that would normally result in the loss of their health insurance coverage are required to file a continuation of coverage election.

How to fill out continuation of coverage election?

To fill out a continuation of coverage election, an individual must typically notify their insurance company within a specified timeframe and complete any necessary paperwork or online forms.

What is the purpose of continuation of coverage election?

The purpose of continuation of coverage election is to ensure that individuals have the option to maintain their health insurance coverage in the event of a qualifying event that would otherwise result in loss of coverage.

What information must be reported on continuation of coverage election?

The information required on a continuation of coverage election typically includes personal details of the individual, details of the qualifying event, and any other relevant information requested by the insurance company.

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