Get the free Cal-Cobra Notification Form 042709

Blue Shield of California Employer Notification of Qualifying Event Under Calibra For employers with 219 eligible employees (219 employees on payroll) Employer: Complete and return to Blue Shield

How to fill out cal-cobra notification form 042709

How to fill out cal-cobra notification form 042709:

1. Begin by providing your personal information such as your full name, address, and contact details.
2. Next, indicate the name and address of your former employer or group health plan administrator.
3. Specify the date on which you experienced a qualifying event that makes you eligible for COBRA coverage, such as termination of employment or reduction of hours.
4. State whether you are electing COBRA coverage for yourself only or for yourself and any eligible dependents.
5. If you are electing COBRA coverage for dependents, provide their names and relationship to you.
6. Indicate if you are covered by any other health insurance plan at the time of your COBRA election.
7. Sign and date the form, certifying that the information provided is accurate to the best of your knowledge.
8. Submit the completed form to the appropriate party, such as your former employer or group health plan administrator.

Who needs cal-cobra notification form 042709?

1. Employees who have experienced a qualifying event that makes them eligible for COBRA coverage.
2. Dependents of the eligible employee who wish to elect COBRA continuation coverage.
3. Former employees who were covered under a group health plan sponsored by their former employer.

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What is cal-cobra notification form 042709?

The cal-cobra notification form 042709 is a form used to notify eligible employees and their dependents of their rights to continue health coverage under the California Continuation Benefits Replacement Act (Cal-COBRA).

Who is required to file cal-cobra notification form 042709?

Employers with 2 to 19 employees are required to file the cal-cobra notification form 042709.

How to fill out cal-cobra notification form 042709?

The cal-cobra notification form 042709 must be filled out with information about the employee, their dependents, the qualifying event, and details of the continuation coverage.

What is the purpose of cal-cobra notification form 042709?

The purpose of cal-cobra notification form 042709 is to inform eligible employees and their dependents of their rights to continue health coverage under Cal-COBRA.

What information must be reported on cal-cobra notification form 042709?

The cal-cobra notification form 042709 must include details about the employee, their dependents, the qualifying event, the health plan, and the cost of continuation coverage.