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CaliforniaEnrollment/Change Form Instructions Section 1: Personal Information Please complete information requested. Section 2: Selected Coverage Select only one of the plans offered by your Employer
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How to fill out cobra-continuation-coverage-activepdf - calpers

01
Download the Cobra Continuation Coverage ActivePDF form from the CalPERS website.
02
Fill in your personal information, including name, address, and social security number.
03
Indicate the reason for needing COBRA coverage and the start date of coverage.
04
Sign and date the form.
05
Submit the completed form to CalPERS according to the instructions provided.

Who needs cobra-continuation-coverage-activepdf - calpers?

01
Individuals who were enrolled in a group health plan provided by an employer participating in CalPERS and experience a qualifying event that makes them eligible for COBRA continuation coverage.
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It is a form used to report information regarding continuation coverage under COBRA through CalPERS.
Employers who offer COBRA coverage through CalPERS are required to file this form.
The form can be filled out online or manually and must include detailed information about the continuation coverage benefits.
The purpose is to report information about COBRA continuation coverage provided through CalPERS.
Information such as the names of covered individuals, coverage dates, and any changes to the coverage must be reported.
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