UT DOH/COBRA Form 116C 2014-2025 free printable template

DOH/COBRA Form 116C 5/2014 Case #: COBRA Health Insurance Information This form MUST be completed by your previous employer or your COBRA insurance company representative. L Any blanks left on this

How to fill out 2014 ut cobra insurance

How to fill out UT DOH/COBRA Form 116C

1. Obtain the UT DOH/COBRA Form 116C from the official website or designated office.
2. Fill out the personal information section, including your full name, address, and contact details.
3. Provide your health insurance information, including policy numbers and coverage details.
4. Indicate the reason for completing the form, such as a qualifying event.
5. Review all filled sections for accuracy and completeness.
6. Sign and date the form where indicated.
7. Submit the completed form to the appropriate UT Department of Health office.

Who needs UT DOH/COBRA Form 116C?

1. Individuals who have experienced a qualifying event that affects their health insurance coverage, such as job loss, reduction in hours, or other life events.

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What is UT DOH/COBRA Form 116C?

UT DOH/COBRA Form 116C is a document required by the Utah Department of Health that enables eligible individuals to continue their health insurance coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) after losing their job or experiencing other qualifying events.

Who is required to file UT DOH/COBRA Form 116C?

Employers with 20 or more employees who offer group health plans are required to file UT DOH/COBRA Form 116C if an employee and their dependents experience a qualifying event that makes them eligible for COBRA continuation coverage.

How to fill out UT DOH/COBRA Form 116C?

To fill out UT DOH/COBRA Form 116C, you need to provide detailed information about the employer, the employee, and the qualifying event. Ensure that all fields are completed accurately, including contact information and dates of the qualifying event.

What is the purpose of UT DOH/COBRA Form 116C?

The purpose of UT DOH/COBRA Form 116C is to notify the Utah Department of Health about the eligibility for COBRA continuation coverage and to provide necessary information for continuation of health benefits to eligible individuals.

What information must be reported on UT DOH/COBRA Form 116C?

The information required on UT DOH/COBRA Form 116C includes the employer's name and address, the employee’s details, the nature of the qualifying event, dates of coverage, and the coverage options available to the employee and their dependents.