Get the free COBRA Election Form - UFCW Local 1189 Benefits Web Site

FCW Local 789 and St. Paul Food Employers Health Care Plan 3001 METRO DRIVE, SUITE 500 BLOOMINGTON, MINNESOTA 55425 9528540795 Election to Continue Health Care Coverage Under COBRA Your name Social

How to fill out cobra election form

How to Fill Out COBRA Election Form:

1. Obtain the COBRA election form: The form can typically be obtained from the employer or the employer's health insurance provider. Contact the HR department or the insurer to request a copy of the form.
2. Read the instructions: Before filling out the form, carefully read the instructions provided. The instructions will guide you through the process and provide important information regarding the time frame, eligibility criteria, and necessary documentation.
3. Fill in personal information: Start by providing your personal details, such as your full name, address, phone number, and social security number. Make sure to double-check the accuracy of the information provided.
4. Select the coverage options: Indicate the specific coverage options you wish to elect. This may include medical, dental, vision, or other types of insurance coverage. Depending on your circumstances, you may also need to indicate coverage options for your dependents.
5. Determine the coverage effective date: COBRA coverage generally starts from the date your previous health insurance coverage ended. Make sure to accurately indicate the start date on the form.
6. Sign and date the form: Before submitting the form, sign and date it in the designated spaces. Your signature certifies that the information provided is accurate to the best of your knowledge.
7. Submit the form: Once the form is completed, submit it according to the instructions provided. This may involve mailing the form to the employer or the insurance provider, hand-delivering it to the HR department, or sending it electronically, depending on the preferred method specified in the instructions.

Who needs COBRA Election Form:

1. Employees who have recently experienced a qualifying event: COBRA election form is typically required by employees who have recently experienced a qualifying event, such as termination of employment, reduction in work hours, or divorce/separation from a covered employee.
2. Dependents of covered employees: If you are a dependent of a covered employee who has experienced a qualifying event, you may also need to fill out a COBRA election form to continue your health insurance coverage.
3. Individuals who want to continue their health insurance coverage: Even if you are not directly impacted by a qualifying event, you may still need to fill out a COBRA election form if you wish to continue your health insurance coverage.

Note: It is important to consult with the employer's HR department or the health insurance provider for specific eligibility criteria and instructions related to the COBRA election form.

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What is cobra election form?

Cobra election form is a form that allows eligible individuals to elect to continue their health coverage under COBRA.

Who is required to file cobra election form?

Any eligible individual who wants to continue their health coverage under COBRA is required to file a cobra election form.

How to fill out cobra election form?

To fill out a cobra election form, individuals must provide their personal information, choose the coverage they wish to continue, and submit the form to the plan administrator.

What is the purpose of cobra election form?

The purpose of cobra election form is to allow eligible individuals to continue their health coverage under COBRA after a qualifying event.

What information must be reported on cobra election form?

The cobra election form must include personal information of the individual, the choice of coverage, and any additional documentation required by the plan administrator.