Get the free COBRA Request Form - University of Texas at Austin
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COBRA Request Form Revised 03/2018Please submit this form to the Human Resource Service Center HR use only Email to: RSC Austin.Texas.edu IR255 Fax to: 5122323524 Mail to: Human Resource Service Center,
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How to fill out cobra request form
How to fill out cobra request form
01
Obtain the cobra request form from your employer or insurance provider.
02
Fill in your personal information such as name, address, and contact details.
03
Provide your previous employer's details, including company name, address, and contact information.
04
Indicate the reason for your cobra request, such as job termination or loss of coverage.
05
Include the date of your eligibility for cobra coverage.
06
Sign and date the form to certify the accuracy of the information provided.
07
Submit the completed form to your employer or insurance provider within the specified timeframe.
Who needs cobra request form?
01
Anyone who has recently experienced job termination or loss of coverage and wishes to continue their health insurance through COBRA (Consolidated Omnibus Budget Reconciliation Act) would need to fill out a cobra request form.
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What is cobra request form?
The COBRA request form is a document that allows individuals to continue their health insurance coverage after experiencing a qualifying event.
Who is required to file cobra request form?
Individuals who have experienced a qualifying event and wish to continue their health insurance coverage are required to file a COBRA request form.
How to fill out cobra request form?
You can fill out a COBRA request form by providing your personal information, details of the qualifying event, and selecting the health insurance coverage you wish to continue.
What is the purpose of cobra request form?
The purpose of a COBRA request form is to allow individuals to maintain their health insurance coverage for a limited period of time after experiencing a qualifying event.
What information must be reported on cobra request form?
The COBRA request form typically requires information such as personal details, details of the qualifying event, and the health insurance coverage options selected.
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