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COBRA Coverage Election Form (Termination or Reduction in Hours of Employment) Date of Notice: ? Mailed ? Hand delivered Qualified Beneficiary Information Name: Last, First, Middle Social Security

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What is cobra coverage election form?

The Cobra coverage election form is a document that allows individuals who have experienced a qualifying event to elect to continue their group health insurance coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA).

Who is required to file cobra coverage election form?

Individuals who have experienced a qualifying event, such as termination of employment, reduction in work hours, divorce, or death of the covered employee, are required to file the Cobra coverage election form if they wish to continue their group health insurance coverage through COBRA.

How to fill out cobra coverage election form?

To fill out the Cobra coverage election form, individuals must provide their personal information, details of the qualifying event, and select the coverage options they wish to elect. The form should be completed accurately and submitted to the appropriate party, such as the employer or the plan administrator.

What is the purpose of cobra coverage election form?

The purpose of the Cobra coverage election form is to notify the employer or plan administrator of an individual's intent to continue their group health insurance coverage through COBRA. It allows individuals to maintain their coverage after a qualifying event, even if they would no longer be eligible under the regular terms of the plan.

What information must be reported on cobra coverage election form?

The Cobra coverage election form typically requires individuals to report their name, contact information, details of the qualifying event, and the coverage options they wish to elect. Additional information may be required depending on the specific requirements of the employer or plan administrator.

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