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1800 Grant Street, Suite 400 400 UCA Denver, CO 80203t 303 860 4200 f 303 860 4299 1 855 216 7740 (toll-free) PBS cu.edu201112 COBRA MEDICAL AND DENTAL ENROLLMENT/CHANGE FORM PARTICIPANT INFORMATION
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How to fill out cobra enrollment form11-12-draft1qxp
How to fill out cobra enrollment form11-12-draft1qxp
01
To fill out the COBRA enrollment form, follow these steps:
02
Start by entering your personal information, such as your name, address, and contact details.
03
Next, provide details about your previous employer and the group health plan you were enrolled in.
04
Indicate the reason for your COBRA eligibility, such as termination of employment, reduction in hours, or death of the covered employee.
05
Specify the coverage you wish to elect, whether it is medical, dental, vision, or a combination.
06
If you have dependents, include their information and indicate if they also want to elect COBRA coverage.
07
Provide any additional information or documentation required by the COBRA administrator.
08
Review the completed form for accuracy and completeness, and sign and date it.
09
Submit the form to the designated COBRA administrator or the employer's HR department as instructed.
10
Make sure to keep a copy of the completed form for your records.
Who needs cobra enrollment form11-12-draft1qxp?
01
The COBRA enrollment form, form11-12-draft1qxp, is needed by individuals who are eligible for COBRA continuation coverage. This may include employees who have recently lost their job, had their work hours reduced, or experienced other qualifying events that caused them to lose their group health coverage. Additionally, dependents of these individuals who were covered under the employer-sponsored health plan may also need to complete the COBRA enrollment form if they wish to continue their coverage.
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