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COBRA F4 (KEPT) 7/09 6/10FOOTHILLDE ANNA COMMUNITY COLLEGE DISTRICT Request For Continuing Health Coverage (KAISER MEDICAL PLAN) NAME OF PERSON TO BE INSURED (please print): SOCIAL SECURITY NUMBER

How to fill out cobra f-4 k-pt

How to fill out cobra f-4 k-pt

1. Start by gathering all the necessary information and documents required to fill out the COBRA F-4 K-PT form.
2. Begin by providing your personal details such as your full name, date of birth, and contact information.
3. Fill in the relevant sections regarding your previous employer and the date of termination of your employment.
4. Specify the reason for your loss of coverage and select the appropriate qualifying event.
5. Indicate whether you wish to continue coverage for yourself, your spouse, and/or dependents.
6. Provide the required information about your health insurance plan and coverage options.
7. Calculate and enter the correct premium amount you will be responsible for paying.
8. Review the completed form for accuracy and make any necessary corrections.
9. Sign and date the form to certify the information provided is true and accurate.
10. Submit the filled-out COBRA F-4 K-PT form to the appropriate party or agency.

Who needs cobra f-4 k-pt?

1. Cobra F-4 K-PT is needed by individuals who have experienced a loss of job-based health insurance coverage due to certain qualifying events such as termination of employment, reduction in work hours, divorce, or a dependent's loss of eligibility. This form is used to apply for continuation of health insurance coverage under the COBRA program.

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What is cobra f-4 k-pt?

Cobra F-4 K-PT refers to a specific form related to the Consolidated Omnibus Budget Reconciliation Act (COBRA) that is used to report certain health insurance coverage details.

Who is required to file cobra f-4 k-pt?

Employers with 20 or more employees who provide group health coverage are required to file COBRA F-4 K-PT.

How to fill out cobra f-4 k-pt?

To fill out COBRA F-4 K-PT, you must provide the necessary employee information, health plan details, and any applicable coverage durations as specified in the form's instructions.

What is the purpose of cobra f-4 k-pt?

The purpose of COBRA F-4 K-PT is to ensure compliance with COBRA regulations by reporting health coverage extensions and notifying eligible individuals of their rights.

What information must be reported on cobra f-4 k-pt?

The information that must be reported includes the names of qualified beneficiaries, the type of health coverage, and the dates of coverage eligibility and termination.