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City of Little Rock Continuation of Benefits Coverage Policy This is NOT a COBRA ELECTION Forename (Last, First, M.I.) Social Security No. EE No. Qualifying Event (Termination, Divorce, etc.) Date
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How to fill out continuation of benefits coverage

01
To fill out continuation of benefits coverage, follow these steps:
02
Obtain the necessary forms from your employer or insurance provider.
03
Read through the forms carefully and make sure you understand the instructions.
04
Provide your personal information, such as your name, address, and contact details.
05
Indicate the reason for needing continuation of benefits coverage, whether it is due to job loss, disability, or other qualifying events.
06
Attach any supporting documents required, such as severance letters, medical certificates, or disability claims.
07
Review your completed forms to ensure all information is accurate and complete.
08
Sign and date the forms.
09
Submit the forms to your employer or insurance provider as instructed.
10
Keep a copy of the filled-out forms and any supporting documents for your records.
11
Follow up with your employer or insurance provider to confirm receipt of your forms and to track the progress of your continuation of benefits coverage.

Who needs continuation of benefits coverage?

01
Continuation of benefits coverage is typically needed by individuals who experience a qualifying event that results in the loss of their current health insurance coverage.
02
Examples of individuals who may need continuation of benefits coverage include:
03
- Employees who have been laid off or terminated from their jobs
04
- Individuals who are transitioning between jobs or experiencing a gap in employment
05
- People who have become disabled and can no longer work
06
- Retirees who are losing their employer-sponsored health insurance
07
- Dependent children who are no longer eligible under their parent's health insurance
08
- Divorced or separated spouses who were covered under their partner's health insurance policy.
09
It is important to consult your employer or insurance provider to determine if you are eligible for continuation of benefits coverage and to understand the specific requirements and procedures involved.

What is Continuation of Benefits Coverage Policy - This is NOT a COBRA ELECTION Form?

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Continuation of Benefits Coverage Policy - This is NOT a COBRA ELECTION template instructions

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Continuation of benefits coverage allows individuals to keep their health insurance coverage after a qualifying event, such as losing a job.
Employers are typically responsible for filing continuation of benefits coverage for their employees.
Continuation of benefits coverage forms can usually be completed online or through the mail, following the instructions provided by the health insurance provider.
The purpose of continuation of benefits coverage is to ensure that individuals have access to health insurance in case of job loss or other qualifying events.
Continuation of benefits coverage forms typically require information about the individual, the qualifying event, and the desired coverage continuation period.
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