Get the free CalPERS COBRA Election Form for Actives

1 PEERS USE ONLY DOCUMENT REFERENCE NUMBER Public Employees' Retirement System Health Account Services P.O. Box 942715 Sacramento, CA 94229-2715 888 Callers (or 888-225-7377) TTY (877) 249-7442 Fax

How to fill out calpers cobra election form

How to fill out calpers cobra election form:

1. Obtain the form: The first step is to get a copy of the calpers cobra election form. You can usually request this form from your employer's HR department or directly from the California Public Employees Retirement System (CalPERS) website.
2. Fill in personal information: Start by providing your personal details such as your name, address, social security number, and contact information. Make sure to double-check the accuracy of the information you provide.
3. Select coverage options: Next, you will need to indicate the coverage options you wish to elect. This includes choosing between continuing current coverage or opting for a different coverage plan. Specify the start and end dates for the coverage you want.
4. Indicate eligible dependents: If you have any eligible dependents who also wish to continue their coverage, make sure to include their information in the form. This includes their names, social security numbers, and relationship to you.
5. Calculate and pay premiums: Use the form to calculate the total premiums for the coverage period you have selected. CalPERS will provide instructions on how to determine the amount you need to pay. Ensure that you include the correct payment or indicate the payment method you will use.
6. Review and sign: Once you have completed all the required sections of the form, carefully review the information you provided. Ensure that everything is accurate and complete before signing and dating the form. Your signature certifies the accuracy of the information you have provided.

Who needs calpers cobra election form:

1. Individuals leaving a job: The calpers cobra election form is typically needed by individuals who are leaving a job where they were previously covered under a CalPERS health insurance plan. It allows them to continue their coverage temporarily under the Consolidated Omnibus Budget Reconciliation Act (COBRA).
2. Eligible dependents: In addition to the primary individual, any eligible dependents who were previously covered under the employer's CalPERS health insurance plan may also need to fill out the calpers cobra election form if they wish to continue their coverage.
3. Those transitioning between plans: If you wish to transition from one CalPERS health insurance plan to another, you may need to complete the calpers cobra election form to indicate your new coverage preferences. This can be necessary when there are changes in your employment or life circumstances that affect your insurance eligibility.

For pdfFiller’s FAQs

What is calpers cobra election form?

The calpers cobra election form is a form that allows eligible individuals to elect to continue their health insurance coverage under COBRA.

Who is required to file calpers cobra election form?

Individuals who experience a qualifying event that causes a loss of health insurance coverage are required to file the calpers cobra election form.

How to fill out calpers cobra election form?

To fill out the calpers cobra election form, eligible individuals must provide their personal information, select the coverage options, and make the required payments.

What is the purpose of calpers cobra election form?

The purpose of the calpers cobra election form is to allow individuals to continue their health insurance coverage for a certain period of time after losing their original coverage.

What information must be reported on calpers cobra election form?

The calpers cobra election form must include personal information, details of the qualifying event, coverage options selected, and payment information.

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