Get the free Continuation Coverage Election Form - DFS.NY.gov

COBRA Continuation Coverage Election Notice Date:Dear: This notice contains important information about your right to continue your health care coverage in the enter name of group health plan (the

How to fill out continuation coverage election form

How to fill out continuation coverage election form

1. Obtain the continuation coverage election form from your employer or insurance provider.
2. Read the instructions carefully to understand the requirements and deadlines.
3. Provide your personal information such as name, address, and contact details in the designated fields.
4. Fill out the form accurately, ensuring all required information is provided.
5. Indicate the type of continuation coverage you are electing and the start date of coverage.
6. Sign and date the form to validate your election.
7. Submit the completed form to your employer or insurance provider within the specified timeframe.
8. Keep a copy of the filled-out form for your records.

Who needs continuation coverage election form?

1. Individuals who have experienced a qualifying event that makes them eligible for continuation coverage, such as the loss of employment or reduction of work hours, may need to fill out the continuation coverage election form. This form is typically required by individuals who wish to continue their health insurance coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) or similar state continuation coverage programs.

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What is continuation coverage election form?

The continuation coverage election form is a document that allows individuals to elect to continue their health insurance coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) after experiencing a qualifying event, such as job loss or reduction in work hours.

Who is required to file continuation coverage election form?

Employers that provide group health plans are required to offer the continuation coverage election form to eligible employees and their dependents after a qualifying event.

How to fill out continuation coverage election form?

To fill out the continuation coverage election form, individuals must provide their personal information, select the type of coverage they wish to continue, and indicate the dependents who will also be covered.

What is the purpose of continuation coverage election form?

The purpose of the continuation coverage election form is to inform individuals of their right to continue health insurance coverage and to allow them to officially elect to do so within the specified time frame.

What information must be reported on continuation coverage election form?

The continuation coverage election form must include the individual's name, address, the dates of coverage, information about qualifying events, and details about which dependents will continue coverage.