Get the free COBRA COVERAGE ELECTION NOTICE - hewitt.conexis.com
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Date: 3/3/2017 Form: CLC02CXHEN Doc ID: 4030186 Account #: 0501768910 CONTEXTS PO Box 660453 Dallas, TX 752660453 To SHANE A MORIN and Covered Dependents 621 Blue Spruce Dr Danville, CA 945064524
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How to fill out cobra coverage election notice
How to fill out cobra coverage election notice
01
Read through the cobra coverage election notice to understand the information provided.
02
Fill in your personal details including your name, address, and social security number.
03
Indicate the reason for your loss of coverage and the date when the coverage was terminated.
04
Select the health insurance plan option you wish to elect under the COBRA coverage.
05
Provide any additional information required by your employer or insurance provider, if applicable.
06
Sign and date the cobra coverage election notice.
07
Submit the completed form to your employer or insurance provider within the specified deadline.
Who needs cobra coverage election notice?
01
Employees who have lost their job and were previously covered under an employer-sponsored health insurance plan.
02
Dependents of covered employees who are no longer eligible for coverage due to certain qualifying events like divorce or death of the covered employee.
03
Retirees who were previously covered under an employer-sponsored health insurance plan.
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