"Cobra Continuation of Coverage Election Form"

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COBRA CONTINUATION OF
COVERAGE ELECTION FORM
Employer _______________________________
Group Policy#_____________________
Persons Electing to Continue Coverage
Date of Birth
SSN
Employee ___________________________________________ _____________
____________
Spouse or Former Spouse______________________________
____________
____________
Child(ren) ___________________________________________
____________
____________
____________________________________________ _____________
____________
Address_____________________________________________________________________________
Qualifying Event
(Check all that apply)
Termination or reduction of hours worked
_________________________________________
Employees Entitlement to Medicare
_________________________________________
Dependent No Longer Eligible
_________________________________________
Divorce _______________
Employee’s Death ______________
EMPLOYER: This is to inform you that I wish to continue my: Dental ____________, Vision __________,
and/or Unreimbursed Medical _________ coverage(s). I have enclosed my monthly premium or will
forward the premium to you within 45 days. I understand that I must pay such premiums on a monthly
basis by (date) ________________, or my coverage(s) will be terminated. I also understand that I am
entitled to a grace period of at least 30 days.
I understand that I am not eligible for continuation of coverage if I am covered under any other group
health plan or eligible for medicare, whether by virtue of my employment or my spouse’s. My eligibility for
COBRA coverage will terminate on the date I am covered by any other group plan or become eligible for
Medicare. If the other group plan I am covered under does not cover a preexisting condition that applies
to me or my dependents, I understand that I may continue my coverage to cover that condition only.*
Are you covered by any other group health plan? Yes __________ No ___________
*If yes, do you have a preexisting condition? ______________________________________________
Signature of Employee ________________________________________ Date __________________
Signature of Spouse or Former Spouse ___________________________ Date __________________
Signature of Child Over 18 _____________________________________ Date __________________
_____________________________________ Date __________________
Sept 2007
COBRA CONTINUATION OF
COVERAGE ELECTION FORM
Employer _______________________________
Group Policy#_____________________
Persons Electing to Continue Coverage
Date of Birth
SSN
Employee ___________________________________________ _____________
____________
Spouse or Former Spouse______________________________
____________
____________
Child(ren) ___________________________________________
____________
____________
____________________________________________ _____________
____________
Address_____________________________________________________________________________
Qualifying Event
(Check all that apply)
Termination or reduction of hours worked
_________________________________________
Employees Entitlement to Medicare
_________________________________________
Dependent No Longer Eligible
_________________________________________
Divorce _______________
Employee’s Death ______________
EMPLOYER: This is to inform you that I wish to continue my: Dental ____________, Vision __________,
and/or Unreimbursed Medical _________ coverage(s). I have enclosed my monthly premium or will
forward the premium to you within 45 days. I understand that I must pay such premiums on a monthly
basis by (date) ________________, or my coverage(s) will be terminated. I also understand that I am
entitled to a grace period of at least 30 days.
I understand that I am not eligible for continuation of coverage if I am covered under any other group
health plan or eligible for medicare, whether by virtue of my employment or my spouse’s. My eligibility for
COBRA coverage will terminate on the date I am covered by any other group plan or become eligible for
Medicare. If the other group plan I am covered under does not cover a preexisting condition that applies
to me or my dependents, I understand that I may continue my coverage to cover that condition only.*
Are you covered by any other group health plan? Yes __________ No ___________
*If yes, do you have a preexisting condition? ______________________________________________
Signature of Employee ________________________________________ Date __________________
Signature of Spouse or Former Spouse ___________________________ Date __________________
Signature of Child Over 18 _____________________________________ Date __________________
_____________________________________ Date __________________
Sept 2007