"Cobra Election Form"

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COBRA ELECTION FORM
To be completed by Employee/Applicant (Please Print)
EMPLOYEE NAME ____________________________________
S.S.#______/_____/_______
STREET ADDRESS ______________________________________________ APT # _________
CITY __________________________________ STATE _______ ZIP CODE _______________
PHONE: WORK (
)_____________________ HOME (
) ______________________
INDICATE QUALIFYING EVENT:
DATE OF QUALIFYING EVENT ______/______/________
____ Termination of Employment
____ Divorce or Legal Separation
____ Reduction in Work Hours
____ Medicare Eligibility
____ Death of Employee
____ Termination of Dependent Eligibility
EMPLOYEE SIGNATURE ________________________________________________________
INDICATE COVERAGE SELECTION:
Medical Coverage
___ I (We) elect NOT to continue coverage under the Group Medical Plan for:
___ Myself
___ My Spouse
___ My Dependent(s)
___ I (We) elect to CONTINUE coverage under the Group Medical Plan for:
___ Myself
___ My Spouse
___ My Dependent(s)
Dental Coverage
___ I (We) elect NOT to continue coverage under the Group Dental Plan for:
___ Myself
___ My Spouse
___ My Dependent(s)
___ I (We) elect to CONTINUE coverage under the Group Dental Plan for:
___ Myself
___ My Spouse
___ My Dependent(s)
Spouse's Name _________________ S.S.# _______/_____/_______ DOB _____/_____/______
Spouse's Street Address _________________________________________________________
City _________________________________________ State _______ Zip Code ___________
Dependent(s):
(The Employee or Spouse MUST complete for all minors)
Dependent Name ________________________S.S.# ____/_____/_____ DOB ____/____/_____
Dependent Name ________________________S.S.# ____/_____/_____ DOB ____/____/_____
Dependent Name ________________________S.S.# ____/_____/_____ DOB ____/____/_____
COBRA ELECTION FORM
To be completed by Employee/Applicant (Please Print)
EMPLOYEE NAME ____________________________________
S.S.#______/_____/_______
STREET ADDRESS ______________________________________________ APT # _________
CITY __________________________________ STATE _______ ZIP CODE _______________
PHONE: WORK (
)_____________________ HOME (
) ______________________
INDICATE QUALIFYING EVENT:
DATE OF QUALIFYING EVENT ______/______/________
____ Termination of Employment
____ Divorce or Legal Separation
____ Reduction in Work Hours
____ Medicare Eligibility
____ Death of Employee
____ Termination of Dependent Eligibility
EMPLOYEE SIGNATURE ________________________________________________________
INDICATE COVERAGE SELECTION:
Medical Coverage
___ I (We) elect NOT to continue coverage under the Group Medical Plan for:
___ Myself
___ My Spouse
___ My Dependent(s)
___ I (We) elect to CONTINUE coverage under the Group Medical Plan for:
___ Myself
___ My Spouse
___ My Dependent(s)
Dental Coverage
___ I (We) elect NOT to continue coverage under the Group Dental Plan for:
___ Myself
___ My Spouse
___ My Dependent(s)
___ I (We) elect to CONTINUE coverage under the Group Dental Plan for:
___ Myself
___ My Spouse
___ My Dependent(s)
Spouse's Name _________________ S.S.# _______/_____/_______ DOB _____/_____/______
Spouse's Street Address _________________________________________________________
City _________________________________________ State _______ Zip Code ___________
Dependent(s):
(The Employee or Spouse MUST complete for all minors)
Dependent Name ________________________S.S.# ____/_____/_____ DOB ____/____/_____
Dependent Name ________________________S.S.# ____/_____/_____ DOB ____/____/_____
Dependent Name ________________________S.S.# ____/_____/_____ DOB ____/____/_____