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Dol.gov/ebsa. State and local government employees should contact HHS-CMS at www. cms. hhs. gov/COBRAContinuationofCov/ or NewCobraRights cms. Benefit Test Medical testtesttest Reggie Plan Loss of Coverage Eligibility Begins 08/02/2013 09/01/2013 Eligibility Ends 02/01/2015 02/28/2015 Election Form Due 10/14/2013 10/30/2013 The current monthly cost of your COBRA continuation coverage is shown on the Election Form. Customer service hours are 8 00 a.m. to 5 00 p.m. Monday through Friday. Thank...
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How to fill out cobra notice
How to fill out cobra notice
01
Step 1: Obtain a copy of the COBRA Notice form from your employer or insurance provider.
02
Step 2: Read the instructions carefully to understand the information required.
03
Step 3: Fill in your personal details such as name, address, and contact information.
04
Step 4: Provide the necessary information about your previous health insurance coverage.
05
Step 5: Indicate the reason for the qualifying event that makes you eligible for COBRA coverage.
06
Step 6: Include information about your eligible dependents, if applicable.
07
Step 7: Sign and date the COBRA Notice form.
08
Step 8: Submit the completed form to your employer or insurance provider as instructed.
Who needs cobra notice?
01
Employees who have recently lost their job.
02
Employees whose hours have been reduced.
03
Spouses and dependent children of employees who have lost their job or had hours reduced.
04
Employees who have retired or been laid off.
05
Employees who have been terminated for reasons other than gross misconduct.
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