Get the free COBRA Request Form - utexas

This interactive form allows individuals to request COBRA benefits after losing coverage. Users can fill it out electronically and print it for submission to the Human Resource Service Center. Options

How to fill out cobra request form

How to fill out COBRA Request Form

1. Obtain the COBRA Request Form from your employer or their benefits administrator.
2. Fill in your personal information, such as name, address, and contact details.
3. Provide the relevant details about your health insurance plan, including plan name and policy number.
4. Indicate the qualifying event that has made you eligible for COBRA coverage.
5. Include the date of the qualifying event and your separation date, if applicable.
6. Sign and date the form to certify that the information provided is accurate.
7. Submit the completed COBRA Request Form to your employer or plan administrator within the designated time frame.

Who needs COBRA Request Form?

1. Employees who have experienced a qualifying event such as job loss, reduction in hours, or change in employment status.
2. Dependents of employees who are covered under the health plan and are affected by the qualifying event.
3. Retirees who are eligible for continued health coverage under COBRA regulations.

People Also Ask about

Does my employer have to offer COBRA if I quit?

What Happens when the Employer Fails to Comply with COBRA? The recommendation is to first try to work it out directly with the human resources department that provides the insurance. If you meet resistance with the employer on starting COBRA, you may call the Department of Labor to file a complaint.

What are the qualifying reasons for COBRA?

COBRA coverage follows a "qualifying event". An example of a qualifying event would be if your hours were reduced or you lost your job (as long as there was no gross misconduct). Your employer must mail you the COBRA information and forms within 14 days after receiving notification of the qualifying event.

How do I ask my employer for a COBRA?

Check if you qualify by taking the COBRA eligibility survey. Read the COBRA Election Notice. The employer that provided the health insurance will send you a COBRA election notice within 45 days of the qualifying event. This notice will give you your monthly COBRA premium and how to apply.

How do I write a COBRA termination letter?

Required content and form The notice must explain the reason coverage has terminated, provide the date of termination and describe any rights the qualified beneficiary may have to elect alternative group or individual coverage, such as a conversion right (29 C.F.R. 2590.606-4(d)).

For pdfFiller’s FAQs

What is COBRA Request Form?

The COBRA Request Form is a document used by eligible individuals to request continuation of health insurance coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) after experiencing a qualifying event.

Who is required to file COBRA Request Form?

Individuals who have experienced a qualifying event, such as job loss, reduction in hours, or other life events that cause a loss of health coverage, are required to file the COBRA Request Form to maintain their health insurance benefits.

How to fill out COBRA Request Form?

To fill out the COBRA Request Form, individuals should provide accurate personal information, specify the qualifying event, select the desired coverage period, and ensure all sections are completed before submitting it to the plan administrator.

What is the purpose of COBRA Request Form?

The purpose of the COBRA Request Form is to formally notify the health plan of an individual's desire to elect COBRA continuation coverage, allowing them to maintain access to health insurance despite a qualifying event.

What information must be reported on COBRA Request Form?

The information that must be reported on the COBRA Request Form includes the individual's name, address, social security number, details of the qualifying event, selected coverage options, and any relevant dates and signatures.