Get the free CalPERS C.O.B.R.A. Election Form for Retirees

1 Health Account Services P.O. Box 942715 Sacramento, CA 94229-2715 888 Callers (or 888-225-7377) Fax (800) 959-6545 TTY (877) 249-7442 HBD-85R (Rev 6/ 13) SUBJECT: CONSOLIDATED OMNIBUS BUDGET RECONCILIATION

How to fill out calpers cobra election form

How to fill out CalPERS COBRA election form:

1. Begin by carefully reading the instructions provided with the CalPERS COBRA election form. These instructions will guide you through the process of completing the form accurately.
2. Start by entering your personal information in the designated sections of the form. This typically includes your name, address, phone number, and Social Security number.
3. Next, indicate the coverage you are electing by selecting the appropriate options provided. This may include medical, dental, vision, or other types of coverage.
4. Provide information about your qualifying event, which is the reason for your COBRA election. This could be due to the loss of employment, reduction in work hours, divorce, or other qualifying events. Include the date of the qualifying event and any supporting documentation if required.
5. Determine the length of coverage you wish to elect. You may have the option to select coverage for a specific number of months or until a specific end date. Consider your individual circumstances and select the appropriate duration.
6. Calculate the total premium due for the selected coverage period. This is typically based on the monthly premium multiplied by the number of months of coverage. Ensure that you understand the payment process and deadlines.
7. Sign and date the form to certify the accuracy of the information provided. In some cases, you may need a witness or notary to authenticate your signature.
8. Review the completed form for any errors or omissions before submitting it to the appropriate entity. Double-check that all required documentation is included, such as proof of qualifying event or payment.
9. If unsure about any aspect of the form, seek assistance from the appropriate CalPERS or COBRA administrator. They will be able to provide clarification or resolve any issues you may have.

Who needs CalPERS COBRA election form:

1. Employees who have recently experienced a qualifying event that resulted in the loss of their job or a reduction in work hours and want to continue their health insurance coverage.
2. Spouses or dependents of an employee who meet the criteria for a qualifying event and wish to maintain their health insurance coverage.
3. Individuals who were covered under a CalPERS health insurance plan and need to elect COBRA coverage due to divorce, death of the covered employee, or losing dependent status.

For pdfFiller’s FAQs

What is calpers cobra election form?

The CalPERS COBRA election form is a form used to elect continued health coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) for eligible employees and their dependents.

Who is required to file calpers cobra election form?

Employees who have experienced a qualifying event that would result in the loss of their health insurance coverage are required to file a CalPERS COBRA election form.

How to fill out calpers cobra election form?

To fill out the CalPERS COBRA election form, the employee must provide their personal information, details of the qualifying event, select the coverage they wish to continue, and submit the form to the appropriate party.

What is the purpose of calpers cobra election form?

The purpose of the CalPERS COBRA election form is to allow eligible employees and their dependents to continue health insurance coverage after experiencing a qualifying event that would result in the loss of their coverage.

What information must be reported on calpers cobra election form?

The CalPERS COBRA election form must include personal information of the employee and dependents, details of the qualifying event, the choice of coverage continuation, and any required payments.

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