Get the free COBRA EMPLOYER APPLICATION FORM - Beere & Purves
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P.O. Box 71107 Oakland, CA 94612 1.800.617.4729 1.888.270.4707 www.sterlingadministration.com COBRA EMPLOYER APPLICATION FORM Company Name: Tax ID: Street Address: City: State: Phone: Fax: Contact
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How to fill out cobra employer application form
How to fill out cobra employer application form:
01
Begin by gathering all the necessary information and documents. This includes the employer's name, address, and contact information, as well as the employee's personal details such as their name, social security number, and address.
02
Fill in the starting date of the coverage period and the reason for the COBRA qualifying event. This could be due to termination of employment, reduction in hours, or other qualifying events.
03
Provide the employee's dependent information, if applicable. This includes the names and social security numbers of any dependents who are eligible for continuation coverage under COBRA.
04
Indicate the type of coverage being continued, such as medical, dental, or vision insurance.
05
Include any additional information required by the employer or insurance provider, such as the employee's previous coverage details or any special circumstances.
06
Review the completed application form for accuracy and completeness before submitting it.
Who needs cobra employer application form:
01
Employers who offer group health insurance plans to their employees are required to provide the COBRA employer application form. This form is crucial for offering continuation coverage to eligible employees and their dependents when they experience qualifying events that would otherwise result in a loss of coverage.
02
Employees who have experienced a qualifying event, such as termination of employment or a reduction in hours, may need to fill out the COBRA employer application form to continue their health insurance coverage.
03
Dependents of employees who are eligible for COBRA continuation coverage will also need to be listed on the application form, ensuring that they receive the necessary coverage.
Note: It is important to consult with an employer's legal or human resources department for specific instructions and requirements related to filling out the COBRA employer application form.
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