AZ COBRA Enrollment Form - City of Mesa 2016-2025 free printable template

New COBRA enrollees must select the same health plans they were previously enrolled in and may not change until a subsequent qualifying event during an Open Enrollment period or as of a subsequent January 1st if the initial loss of coverage event is occurring in the months of October thru December of the current year. Unless I elect SurePay payments must be made payable to the City of Mesa and delivered directly to the Employee Benefits Office located at 20 E Main Suite 600 Mesa AZ 85201 or...

How to fill out AZ COBRA Enrollment Form - City

How to fill out AZ COBRA Enrollment Form - City of Mesa

1. Obtain the AZ COBRA Enrollment Form from the City of Mesa website or HR department.
2. Read the instructions carefully before filling out the form.
3. Fill in your personal information, including your name, address, and contact details.
4. Provide information about your previous health insurance coverage, including the plan name and policy number.
5. Indicate the reason for enrollment in COBRA coverage.
6. Review the coverage options and select the desired plan.
7. Sign and date the form to confirm your election of COBRA continuation coverage.
8. Submit the completed form to the designated department or individual as instructed.

Who needs AZ COBRA Enrollment Form - City of Mesa?

1. Individuals who have recently lost their health insurance coverage due to job loss or other qualifying events.
2. Employees of the City of Mesa who are eligible for COBRA continuation coverage.
3. Dependents of employees who were covered under the health plan and have experienced a qualifying event.

For pdfFiller’s FAQs

How can I send AZ COBRA Enrollment Form - City for eSignature?

Once your AZ COBRA Enrollment Form - City is ready, you can securely share it with recipients and collect eSignatures in a few clicks with pdfFiller. You can send a PDF by email, text message, fax, USPS mail, or notarize it online - right from your account. Create an account now and try it yourself.

How do I make changes in AZ COBRA Enrollment Form - City?

pdfFiller not only allows you to edit the content of your files but fully rearrange them by changing the number and sequence of pages. Upload your AZ COBRA Enrollment Form - City to the editor and make any required adjustments in a couple of clicks. The editor enables you to blackout, type, and erase text in PDFs, add images, sticky notes and text boxes, and much more.

Can I create an eSignature for the AZ COBRA Enrollment Form - City in Gmail?

You may quickly make your eSignature using pdfFiller and then eSign your AZ COBRA Enrollment Form - City right from your mailbox using pdfFiller's Gmail add-on. Please keep in mind that in order to preserve your signatures and signed papers, you must first create an account.

What is AZ COBRA Enrollment Form - City of Mesa?

The AZ COBRA Enrollment Form - City of Mesa is a document that allows eligible individuals to enroll in continuation health coverage under COBRA after losing their employer-sponsored health insurance benefits.

Who is required to file AZ COBRA Enrollment Form - City of Mesa?

Individuals who have experienced a qualifying event, such as job loss, reduction in hours, or other circumstances that result in loss of health insurance coverage through the City of Mesa, are required to file the AZ COBRA Enrollment Form.

How to fill out AZ COBRA Enrollment Form - City of Mesa?

To fill out the AZ COBRA Enrollment Form, individuals should provide their personal information, including name, address, and contact details, as well as information regarding their previous health insurance coverage and qualifying event.

What is the purpose of AZ COBRA Enrollment Form - City of Mesa?

The purpose of the AZ COBRA Enrollment Form - City of Mesa is to enable eligible individuals to enroll in COBRA continuation coverage, ensuring they can maintain access to health insurance after losing their employment or group health benefits.

What information must be reported on AZ COBRA Enrollment Form - City of Mesa?

The AZ COBRA Enrollment Form must include personal identification details, information about the previous health insurance coverage, the date of the qualifying event, and any relevant financial details, such as premium payment options.