Get the free COBRA Election Form - CalHR - State of California - calhr ca

Print Form STATE OF CALIFORNIA DEPARTMENT OF HUMAN RESOURCES CalHR689 Reset Form Rev. 03/2012 CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA) DESELECT PROGRAM CONTINUATION COBRA ELECTION FORM

How to fill out cobra election form

How to fill out cobra election form:

1. Obtain the form: The first step is to obtain a copy of the cobra election form. You can typically get this form from your employer or the health plan administrator.
2. Provide personal information: Fill out the required personal information on the form, such as your name, address, and contact details. Make sure to double-check the accuracy of the information provided.
3. Specify the qualifying event: Indicate the qualifying event that makes you eligible for COBRA coverage. This could be a job loss, reduction in work hours, or other qualifying events specified under the law.
4. Choose coverage options: Select the type of coverage you wish to elect, whether it is for yourself only or for your entire family. You may have different options available, such as medical, dental, and vision coverage.
5. Verify dependent information: If you are electing coverage for your dependents, provide their information as well. This may include their names, dates of birth, and relationship to you.
6. Sign and date the form: Once you have completed all the required fields, sign and date the form to certify the accuracy of the information provided.
7. Keep a copy: Make a copy of the filled-out form for your records before submitting it to the appropriate party.

Who needs cobra election form:

1. Employees who experienced a qualifying event: The COBRA election form is necessary for employees who have experienced a qualifying event, such as termination of employment, reduction in work hours, or other events that result in loss of health insurance coverage.
2. Dependents of the covered employee: If the qualifying event affects the coverage of dependents, they may also need to fill out the COBRA election form to elect continued coverage.
3. Individuals seeking continuation of health coverage: Anyone who wishes to continue their health insurance coverage under COBRA after experiencing a qualifying event will need to complete the cobra election form. This ensures that they have the opportunity to maintain the same level of coverage as before the qualifying event.

Note: It is always advisable to consult with your employer or the health plan administrator for specific instructions on how to fill out the COBRA election form.

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What is cobra election form?

The COBRA election form is a form that allows eligible individuals to elect continuation of their group health coverage.

Who is required to file cobra election form?

Employees and their dependents who experience a qualifying event that triggers COBRA eligibility are required to file the COBRA election form.

How to fill out cobra election form?

Individuals can fill out the COBRA election form by providing their personal information, identifying the qualifying event, and selecting the coverage options they wish to continue.

What is the purpose of cobra election form?

The purpose of the COBRA election form is to give individuals the opportunity to continue health coverage after experiencing a qualifying event.

What information must be reported on cobra election form?

The COBRA election form must include personal information of the individual, details of the qualifying event, coverage options, and any other required information specified in the form.