"Special Enrollment Rights Notice and Waiver Form - Choice Cobra"

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Date: ____________________
Dear Employee or Spouse:
If you are declining enrollment for yourself or your dependents (including your spouse) because
of other health insurance or group health plan coverage, you may be able to enroll yourself and
your dependents in this plan if you or your dependents lose eligibility for that other coverage (or
if the employer stops contributing towards you or your dependents’ other coverage). However,
you must request enrollment within 30 days after you or your dependents’ other coverage ends
(or after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement
for adoption, you may be able to enroll yourself and your dependents, provided that you request
enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.
“I have read and understand the above notification. I understand that if I decline plan coverage, I
will only be able to obtain such coverage upon the plan’s open enrollment period or because of
one or more of the events listed above.”
To request special enrollment or obtain more information, contact
________________________________ at _____________________________________.
I am declining medical and/or dental coverage effective _______________________________
under the company plan due to the following reason(s). If due to other coverage, please list
your current carrier and identification number.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Coverage being declined:
Medical
Dental
Current Carrier(s): _____________________________
ID#: _______________________________
Current Carrier(s): _____________________________
ID#: _______________________________
Print Name: _________________________________
Signature: __________________________________
Date: _________________________
Social Security Number: _______________________
t 401-921-3514
f 401-921-3518
3649 Post Road, Warwick, RI 02886
info@cobra-admin.com
Date: ____________________
Dear Employee or Spouse:
If you are declining enrollment for yourself or your dependents (including your spouse) because
of other health insurance or group health plan coverage, you may be able to enroll yourself and
your dependents in this plan if you or your dependents lose eligibility for that other coverage (or
if the employer stops contributing towards you or your dependents’ other coverage). However,
you must request enrollment within 30 days after you or your dependents’ other coverage ends
(or after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement
for adoption, you may be able to enroll yourself and your dependents, provided that you request
enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.
“I have read and understand the above notification. I understand that if I decline plan coverage, I
will only be able to obtain such coverage upon the plan’s open enrollment period or because of
one or more of the events listed above.”
To request special enrollment or obtain more information, contact
________________________________ at _____________________________________.
I am declining medical and/or dental coverage effective _______________________________
under the company plan due to the following reason(s). If due to other coverage, please list
your current carrier and identification number.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Coverage being declined:
Medical
Dental
Current Carrier(s): _____________________________
ID#: _______________________________
Current Carrier(s): _____________________________
ID#: _______________________________
Print Name: _________________________________
Signature: __________________________________
Date: _________________________
Social Security Number: _______________________
t 401-921-3514
f 401-921-3518
3649 Post Road, Warwick, RI 02886
info@cobra-admin.com