Get the free Cobra Continuation Election Form

This form is required to elect or decline COBRA continuation coverage after a qualifying event such as termination or reduction in hours. It must be filled out completely and returned within 60 days of separation.

How to fill out cobra continuation election form

How to fill out cobra continuation election form

1. Obtain the COBRA continuation election form from your employer's benefits administrator or HR department.
2. Carefully read the instructions provided with the form to understand the requirements.
3. Fill out your personal information at the top of the form, including your name, address, and Social Security number.
4. Indicate the qualifying event that entitled you to COBRA coverage, such as termination of employment or reduction in hours.
5. Select the coverage options you wish to elect for yourself and any dependents.
6. Review the premiums for the selected coverage options and ensure you understand your payment responsibilities.
7. Sign and date the form to certify that the information provided is accurate.
8. Submit the completed form to your employer's benefits administrator by the specified deadline.

Who needs cobra continuation election form?

1. Employees who experience a qualifying event such as job loss, reduction in hours, divorce, or death of the covered employee.
2. Dependent beneficiaries of the covered employee who wish to continue their health insurance coverage after a qualifying event.

For pdfFiller’s FAQs

How can I send cobra continuation election form to be eSigned by others?

When your cobra continuation election form is finished, send it to recipients securely and gather eSignatures with pdfFiller. You may email, text, fax, mail, or notarize a PDF straight from your account. Create an account today to test it.

Can I create an electronic signature for signing my cobra continuation election form in Gmail?

With pdfFiller's add-on, you may upload, type, or draw a signature in Gmail. You can eSign your cobra continuation election form and other papers directly in your mailbox with pdfFiller. To preserve signed papers and your personal signatures, create an account.

How do I edit cobra continuation election form on an iOS device?

Create, modify, and share cobra continuation election form using the pdfFiller iOS app. Easy to install from the Apple Store. You may sign up for a free trial and then purchase a membership.

What is cobra continuation election form?

The COBRA continuation election form is a document that allows eligible individuals to elect to continue their health insurance coverage after experiencing a qualifying event that results in the loss of coverage.

Who is required to file cobra continuation election form?

Individuals who have experienced a qualifying event, such as job loss, reduction in work hours, or other events that affect health insurance eligibility, are required to file the COBRA continuation election form.

How to fill out cobra continuation election form?

To fill out the COBRA continuation election form, individuals should complete the form provided by their employer or health plan administrator, ensuring that all personal information and election choices are clearly indicated, and submit it according to the instructions provided.

What is the purpose of cobra continuation election form?

The purpose of the COBRA continuation election form is to formally allow eligible individuals the option to maintain their group health insurance coverage for a limited time after a qualifying event.

What information must be reported on cobra continuation election form?

The COBRA continuation election form must include information such as the individual's name, address, social security number, the name of the health plan, the qualifying event, and the specific coverage being elected.