Get the free COBRA - Illinois Department of Central Management Services
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Request for Retroactive Member Change For eligibility request changes greater than 60 days retroactive Section 1 Insured Information Name of InsuredGender:MaleStudent IDATE of Birth/Beale Street Address
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How to fill out cobra - illinois department
How to fill out cobra - illinois department
01
Obtain the COBRA enrollment form from the Illinois Department of Insurance or your employer.
02
Fill out the form with your personal information, including your name, address, social security number, and contact information.
03
Indicate the reason for losing your employer-sponsored health insurance coverage.
04
Select the health insurance plan you wish to continue under COBRA.
05
Sign and date the form before submitting it to the Illinois Department of Insurance or your employer.
Who needs cobra - illinois department?
01
Employees who have lost or will lose their employer-sponsored health insurance coverage due to a qualifying event such as termination of employment, reduction in hours, divorce, or death.
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What is cobra - illinois department?
COBRA stands for the Consolidated Omnibus Budget Reconciliation Act, which allows employees to continue their health insurance coverage after leaving their job.
Who is required to file cobra - illinois department?
Employers with 20 or more employees who offer health insurance benefits are required to offer COBRA coverage.
How to fill out cobra - illinois department?
Employers can fill out the necessary COBRA forms provided by the Illinois Department of Insurance and submit them to the department.
What is the purpose of cobra - illinois department?
The purpose of COBRA is to provide employees with the option to continue their health insurance coverage for a certain period of time after leaving their job.
What information must be reported on cobra - illinois department?
Employers must report information about the employee, the health insurance plan, and the COBRA coverage being offered.
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