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COBRA ADDRESS NOTIFICATION FORM To the covered employee, If you have a dependent that is covered by our group health plan whose legal residence is not yours (dependent child covered by court order,

How to fill out cobra address notification form

How to fill out cobra address notification form:

1. Start by entering your personal information such as your full name, social security number, and contact information in the designated fields.
2. Next, provide your previous address along with the effective date of your change of address.
3. Fill in your new address details including the street address, city, state, and zip code.
4. If applicable, provide any additional information requested on the form such as your employer's name and contact information.
5. Review the form to ensure all the information provided is accurate and complete.
6. Sign and date the form at the bottom to certify the accuracy of the information provided.
7. Submit the completed form to the appropriate entity, such as your former employer's human resources department or the cobra administrator.

Who needs cobra address notification form:

1. Individuals who are enrolled in a group health plan offered by their former employer and have elected to continue their coverage through COBRA.
2. COBRA stands for Consolidated Omnibus Budget Reconciliation Act and allows eligible individuals to temporarily continue their health insurance coverage after experiencing a qualifying event that would otherwise result in loss of coverage.
3. If you have recently moved or changed your address, you need to fill out the COBRA address notification form to update your contact information with the plan administrator.
4. It is important to keep your address updated to ensure that you receive important communication regarding your COBRA coverage, such as premium payment notices and benefit information.

For pdfFiller’s FAQs

What is cobra address notification form?

The cobra address notification form is a document used to update the contact information of individuals enrolled in COBRA continuation coverage.

Who is required to file cobra address notification form?

Employers or plan administrators are required to file the cobra address notification form for individuals enrolled in COBRA continuation coverage.

How to fill out cobra address notification form?

The cobra address notification form can be filled out by providing the individual's name, old address, new address, and any other required information. It can usually be submitted online or by mail.

What is the purpose of cobra address notification form?

The purpose of the cobra address notification form is to ensure that individuals enrolled in COBRA continuation coverage receive important information regarding their health benefits.

What information must be reported on cobra address notification form?

The cobra address notification form must include the individual's name, old address, new address, and any other required contact information.

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