Form CALHR689 "Cobra Continuation Election Form - Flexelect Program" - California

What Is Form CALHR689?

This is a legal form that was released by the California Department of Human Resources - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2016;
  • The latest edition provided by the California Department of Human Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form CALHR689 by clicking the link below or browse more documents and templates provided by the California Department of Human Resources.

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Download Form CALHR689 "Cobra Continuation Election Form - Flexelect Program" - California

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FlexElect Program
COBRA Continuation Election Form
California Department of Human Resources
Print Form
Reset Form
State of California
1. Enrollee Information
Enrollee Name
Enrollee Social Security Number
Enrollee Mailing Address (Street)
Enrollee Mailing Address (City, State, ZIP Code)
Enrollee Daytime Phone Number
Date Mailed or Given to Enrollee
2. Election to Enroll in COBRA Continuation Coverage for Medical Reimbursement Account
Effective Date
I elect to enroll in Consolidated Omnibus Budget Reconciliation Act
(COBRA) Continuation Coverage to continue my coverage for my
Medical Reimbursement Account. (Please check the box on the left.)
Signature of Enrollee
Date Signed
3. Deadline to Return this Form
The election form must be completed and returned to the
Day 60 After the Event
address shown below by this date. If mailed, it must be
postmarked by this date.
4. Required Forms and Payment
You must complete and include:
This form
The enclosed Reimbursement Account Enrollment Authorization (STD. 701 R)
Your initial COBRA payment
The monthly 2% administrative fee
5. Submit Items To
Agency Name
Agency Mailing Address (Street, City, State, ZIP Code)
Your Personnel Office will forward the completed STD. 701R form and your COBRA payment to CalHR
for processing. CalHR will send you a COBRA Enrollment Confirmation Letter with instructions for future
contributions into your account.
CalHR 689
(rev 07/2016)
Page 1 of 2
FlexElect Program
COBRA Continuation Election Form
California Department of Human Resources
Print Form
Reset Form
State of California
1. Enrollee Information
Enrollee Name
Enrollee Social Security Number
Enrollee Mailing Address (Street)
Enrollee Mailing Address (City, State, ZIP Code)
Enrollee Daytime Phone Number
Date Mailed or Given to Enrollee
2. Election to Enroll in COBRA Continuation Coverage for Medical Reimbursement Account
Effective Date
I elect to enroll in Consolidated Omnibus Budget Reconciliation Act
(COBRA) Continuation Coverage to continue my coverage for my
Medical Reimbursement Account. (Please check the box on the left.)
Signature of Enrollee
Date Signed
3. Deadline to Return this Form
The election form must be completed and returned to the
Day 60 After the Event
address shown below by this date. If mailed, it must be
postmarked by this date.
4. Required Forms and Payment
You must complete and include:
This form
The enclosed Reimbursement Account Enrollment Authorization (STD. 701 R)
Your initial COBRA payment
The monthly 2% administrative fee
5. Submit Items To
Agency Name
Agency Mailing Address (Street, City, State, ZIP Code)
Your Personnel Office will forward the completed STD. 701R form and your COBRA payment to CalHR
for processing. CalHR will send you a COBRA Enrollment Confirmation Letter with instructions for future
contributions into your account.
CalHR 689
(rev 07/2016)
Page 1 of 2
PRIVACY NOTICE
This notice is provided pursuant to the Information Practices Act of 1977.
The California Department of Human Resources (CalHR), Benefits Division, and the FlexElect
Administrator are requesting the information specified on this form pursuant to Government Code
Sections 1151, 1153, Section 6011 and 6051 of the Internal Revenue Code, and Regulation 4, Section
404.1256, Code of Federal Regulations, under Section 218, Title II of the Social Security Act.
The information collected will be used for administering FlexElect Program COBRA Continuation
benefits and will be disclosed to the FlexElect administrator.
Individuals should not provide personal information that is not requested or required.
The submission of all information requested is mandatory unless otherwise noted. If you fail to provide
the information requested, CalHR will not be able to process your request for FlexElect Program
COBRA Continuation benefits.
Department Privacy Policy
The information collected by CalHR is subject to the limitations in the Information Practices Act of 1977
and state policy. For more information on how we care for your personal information, please read our
Privacy Policy on CalHR's website (calhr.ca.gov).
Access to Your Information
Information provided on this form will be maintained in confidential files of CalHR for five years.
Individuals have the right of access to copies of this form on request. Send requests to:
CalHR Privacy Officer
1515 S Street, North Building, Suite 500
Sacramento, California 95811-7258
916-324-0455
CalHRPrivacy@calhr.ca.gov
CalHR 689
(rev 07/2016)
Page 2 of 2
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