Get the free COBRA Change Form 9-04 - National Plan Administrators

COBRA CHANGE FORM FORMER EMPLOYER NAME: PUB / EMPLOYEE NAME: SS#: ADDRESS: PHONE#: I have experienced the following change within the last 30 days and I wish to add to, change or cancel my existing

How to fill out cobra change form 9-04

How to fill out cobra change form 9-04?

1. Start by entering your personal information: Provide your full name, social security number, and address in the designated fields on the form. Make sure to double-check the accuracy of this information before proceeding.
2. Indicate the date of the qualifying event: The cobra change form 9-04 requires you to specify the date on which the qualifying event that triggered your COBRA eligibility occurred. This could include events such as termination of employment, reduction in hours, or loss of dependent status. Write down the exact date in the provided section.
3. Choose the type of coverage change: Next, select the appropriate box to indicate whether you are making a change to your health coverage, dental coverage, or vision coverage. If you need to make changes to multiple coverages, additional forms may be required.
4. Provide details of the coverage change: In this section, you must explain the reason for the change in coverage. Whether you are adding or removing dependents, switching plans, or terminating coverage altogether, clearly state the details and any relevant information.
5. Sign and date the form: Once you have completed all the necessary sections, verify that you have accurately filled out the form and then sign and date it. By signing, you are certifying that the information provided is true and accurate to the best of your knowledge.

Who needs cobra change form 9-04?

1. Employees who have experienced a qualifying event: The cobra change form 9-04 is typically used by employees who have experienced a qualifying event that makes them eligible for COBRA continuation coverage. Examples of qualifying events include termination of employment, reduction in hours, divorce or legal separation, and loss of dependent status.
2. Individuals who wish to make changes to their COBRA coverage: If you are currently enrolled in COBRA continuation coverage and need to make changes to your existing coverage, you will need to fill out the cobra change form 9-04. This form allows you to update your health, dental, or vision coverage, add or remove dependents, switch plans, or terminate coverage altogether.
3. Employers or COBRA administrators: Employers or COBRA administrators may also use the cobra change form 9-04 when processing changes to COBRA continuation coverage for their employees. It allows them to accurately document and track changes made to the coverage and ensure compliance with COBRA regulations.

For pdfFiller’s FAQs

What is cobra change form 9-04?

Cobra Change Form 9-04 is a form used to update information regarding COBRA coverage.

Who is required to file cobra change form 9-04?

Employers, plan administrators, or individuals who need to update information related to COBRA coverage are required to file Cobra Change Form 9-04.

How to fill out cobra change form 9-04?

Cobra Change Form 9-04 can be filled out by providing accurate information regarding the changes in COBRA coverage and submitting it to the relevant party.

What is the purpose of cobra change form 9-04?

The purpose of Cobra Change Form 9-04 is to ensure that the information related to COBRA coverage is up to date and accurate.

What information must be reported on cobra change form 9-04?

Information such as the change in coverage, effective date of the change, and any other relevant details must be reported on Cobra Change Form 9-04.

How can I edit cobra change form 9-04 from Google Drive?

People who need to keep track of documents and fill out forms quickly can connect PDF Filler to their Google Docs account. This means that they can make, edit, and sign documents right from their Google Drive. Make your cobra change form 9-04 into a fillable form that you can manage and sign from any internet-connected device with this add-on.

How do I edit cobra change form 9-04 straight from my smartphone?

The pdfFiller apps for iOS and Android smartphones are available in the Apple Store and Google Play Store. You may also get the program at https://edit-pdf-ios-android.pdffiller.com/. Open the web app, sign in, and start editing cobra change form 9-04.

How do I fill out the cobra change form 9-04 form on my smartphone?

On your mobile device, use the pdfFiller mobile app to complete and sign cobra change form 9-04. Visit our website (https://edit-pdf-ios-android.pdffiller.com/) to discover more about our mobile applications, the features you'll have access to, and how to get started.