Get the free COBRA Dependent Change Form - BMS LLC

BMS LLC P.O. Box 43653, Louisville, KY 40253-0653 (502) 244-1161 * FAX (502) 244-1162 COBRA Dependent Change Form (Please write legibly.) Company Name Employee Name: Employee Address (city state,

How to fill out cobra dependent change form

How to fill out COBRA Dependent Change Form?

1. Start by obtaining a copy of the COBRA Dependent Change Form. You can usually find this form on your employer's website or by contacting your benefits administrator.
2. Begin by filling out your personal information at the top of the form, including your name, address, phone number, and employee identification number.
3. Indicate the reason for making changes to your dependent coverage. This could include marriage, divorce, birth, adoption, or any other qualifying event that affects your dependents' eligibility.
4. Provide the details of the dependent(s) you wish to add or remove from your COBRA coverage. This will include their full names, dates of birth, and relationship to you (spouse, child, etc.).
5. If you are adding dependents, make sure to attach any required documentation. This may include birth certificates, adoption papers, or marriage certificates. Check the instructions on the form to see which documents are needed.
6. If you are removing dependents, provide a detailed explanation of the reason for the removal. For example, if a child is no longer eligible due to age, indicate the date of their birth and when they turned ineligible according to your plan's guidelines.
7. Review the completed form carefully to ensure accuracy. Double-check all the information provided and make any necessary corrections.
8. Sign and date the form at the bottom to certify that the information provided is true and accurate to the best of your knowledge.

Who needs COBRA Dependent Change Form?

1. Employees who experience a qualifying event that affects the eligibility of their dependents for COBRA coverage need to fill out the COBRA Dependent Change Form.
2. This form is necessary for individuals who get married, divorced, have a child, adopt a child, or experience any other qualifying event outlined in the COBRA guidelines that would impact their dependent coverage.
3. It is important to submit the COBRA Dependent Change Form promptly to ensure that your dependents are properly included or excluded from your COBRA coverage. Failure to do so within the required timeframe could result in a loss of benefits for your dependents.

For pdfFiller’s FAQs

What is cobra dependent change form?

The Cobra dependent change form is a document used to make changes to dependents covered under a Cobra health insurance plan.

Who is required to file cobra dependent change form?

The primary plan holder or the dependent themselves may be required to file the Cobra dependent change form, depending on the circumstances.

How to fill out cobra dependent change form?

The form typically requires providing personal information of the dependent, the requested change, and any supporting documentation.

What is the purpose of cobra dependent change form?

The purpose of the Cobra dependent change form is to update the list of dependents covered under a Cobra health insurance plan.

What information must be reported on cobra dependent change form?

The form may require information such as the dependent's name, date of birth, relationship to the primary plan holder, and any changes to coverage.

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