"Cobra Continuation Services - Benefit Termination Form" - California

This "Cobra Continuation Services - Benefit Termination Form" is a part of the paperwork released by the California Department of Managed Health Care specifically for California residents.

The latest fillable version of the document was released on May 20, 2013 and can be downloaded through the link below or found through the department's forms library.

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Download "Cobra Continuation Services - Benefit Termination Form" - California

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Capital Administrators (CA)
COBRA Continuation Services - Benefit Termination Form
(Also used to collect information for current COBRA qualified beneficiaries when taking over COBRA administration)
(revised 5/20/2013)
INSTRUCTIONS: Please print clearly
COMPLETE THIS FORM AND RETURN IT TO:
1. Fill out one form per family unit (Qualified Beneficiary and Dependents)
Capital Administrators
3819 Market Street
2. Please check one box:
Original notice (if faxed, do not mail copy)
Revision to original
Camp Hill, PA 17011
Fax: 717-975-9303
1. Company:
2. Please be advised that the following is currently on COBRA Continuation (Check one box only):
Employee
Dependent
3. Social Security Number of Qualified Beneficiary: ____ ____ ____ - ____ ____ - ____ ____ ____ ____
4. Name of COBRA Continuation continuant (last, first, mi):
5a. Street Address:
5b. City:
5c. State:
5d. Zip:
6. Home Phone:
7. Date of Birth:
8. Gender:
Male
Female
9. Marital Status:
Single
Married
Widowed
Divorced
10. If the individual indicated in box #4 is a dependent of an employee/former employee, please complete the following:
Employee Name (last, first, mi):______________________________________Continuant’s relationship to employee:________________________
Employee’s SSN: ____ ____ ____ - ____ ____ - ____ ____ ____ ____
11. Qualifying Event that caused loss of coverage (check one):
Continuation of coverage for 18 months for Federal COBRA or 9 months for Mini-COBRA:
Employee’s involuntary termination of employment (except when due to gross misconduct)
Employee’s voluntary resignation/termination of employment
EFFECTIVE
Employee’s retirement
DATE OF
Employee’s layoff or leave of absence
-
Please circle one
Employee’s reduction in work hours (includes work stoppage or strike)
QUALIFYING
Other (please describe): ___________________________________________________
EVENT
Continuation of coverage for 36 months for Federal COBRA or 9 months for Mini-COBRA:
INDICATED:
Death of covered employee/retiree
Divorce/legal separation
Covered employee/retiree becomes entitled to Medicare; dependents may elect continuance of group coverage
____________
Ineligibility of dependent child
Retiree, spouse or child of retiree loses coverage within one year before or after commencement of proceedings
under Title 11 (bankruptcy)
12. Last day of pre-COBRA coverage:
____________________________________________
13. First premium due-date for which CA is to begin COBRA Continuation billing: ___________________________
14. What types of coverage is the continuant enrolled in:
Health
Vision
Dental
FSA
Other ___________________
15. What tier is the continuant enrolled in for health? CA administers only plan code coverage options that are permitted by your plan or carrier.
Employee
Employee + Spouse/Domestic Partner
Employee + Child
Employee + Children
Family
16. What tier is the continuant enrolled in for vision? CA administers only plan code coverage options that are permitted by your plan or carrier.
Employee
Employee + Spouse/Domestic Partner
Employee + Child
Employee + Children
Family
17. What tier is the continuant enrolled in for dental? CA administers only plan code coverage options that are permitted by your plan or carrier.
Employee
Employee + Spouse/Domestic Partner
Employee + Child
Employee + Children
Family
18. FSA Payroll Information:
Last payroll deduction amount (medical FSA)
_________________
Last payroll deduction amount (dependent care FSA)
_________________
Last payroll deduction date
_________________
Annual allocation (if CA is not the administrator)
_________________
Current plan year claims approved (if CA is not the administrator)
_________________
19. Has the continuant been approved for an additional 11-month disability extension?
No
Yes
20. At the time of the separation or reduction in hours was the employee eligible to receive Social Security income?
No
Yes
21. Form Complete by:
Date:
Capital Administrators (CA)
COBRA Continuation Services - Benefit Termination Form
(Also used to collect information for current COBRA qualified beneficiaries when taking over COBRA administration)
(revised 5/20/2013)
INSTRUCTIONS: Please print clearly
COMPLETE THIS FORM AND RETURN IT TO:
1. Fill out one form per family unit (Qualified Beneficiary and Dependents)
Capital Administrators
3819 Market Street
2. Please check one box:
Original notice (if faxed, do not mail copy)
Revision to original
Camp Hill, PA 17011
Fax: 717-975-9303
1. Company:
2. Please be advised that the following is currently on COBRA Continuation (Check one box only):
Employee
Dependent
3. Social Security Number of Qualified Beneficiary: ____ ____ ____ - ____ ____ - ____ ____ ____ ____
4. Name of COBRA Continuation continuant (last, first, mi):
5a. Street Address:
5b. City:
5c. State:
5d. Zip:
6. Home Phone:
7. Date of Birth:
8. Gender:
Male
Female
9. Marital Status:
Single
Married
Widowed
Divorced
10. If the individual indicated in box #4 is a dependent of an employee/former employee, please complete the following:
Employee Name (last, first, mi):______________________________________Continuant’s relationship to employee:________________________
Employee’s SSN: ____ ____ ____ - ____ ____ - ____ ____ ____ ____
11. Qualifying Event that caused loss of coverage (check one):
Continuation of coverage for 18 months for Federal COBRA or 9 months for Mini-COBRA:
Employee’s involuntary termination of employment (except when due to gross misconduct)
Employee’s voluntary resignation/termination of employment
EFFECTIVE
Employee’s retirement
DATE OF
Employee’s layoff or leave of absence
-
Please circle one
Employee’s reduction in work hours (includes work stoppage or strike)
QUALIFYING
Other (please describe): ___________________________________________________
EVENT
Continuation of coverage for 36 months for Federal COBRA or 9 months for Mini-COBRA:
INDICATED:
Death of covered employee/retiree
Divorce/legal separation
Covered employee/retiree becomes entitled to Medicare; dependents may elect continuance of group coverage
____________
Ineligibility of dependent child
Retiree, spouse or child of retiree loses coverage within one year before or after commencement of proceedings
under Title 11 (bankruptcy)
12. Last day of pre-COBRA coverage:
____________________________________________
13. First premium due-date for which CA is to begin COBRA Continuation billing: ___________________________
14. What types of coverage is the continuant enrolled in:
Health
Vision
Dental
FSA
Other ___________________
15. What tier is the continuant enrolled in for health? CA administers only plan code coverage options that are permitted by your plan or carrier.
Employee
Employee + Spouse/Domestic Partner
Employee + Child
Employee + Children
Family
16. What tier is the continuant enrolled in for vision? CA administers only plan code coverage options that are permitted by your plan or carrier.
Employee
Employee + Spouse/Domestic Partner
Employee + Child
Employee + Children
Family
17. What tier is the continuant enrolled in for dental? CA administers only plan code coverage options that are permitted by your plan or carrier.
Employee
Employee + Spouse/Domestic Partner
Employee + Child
Employee + Children
Family
18. FSA Payroll Information:
Last payroll deduction amount (medical FSA)
_________________
Last payroll deduction amount (dependent care FSA)
_________________
Last payroll deduction date
_________________
Annual allocation (if CA is not the administrator)
_________________
Current plan year claims approved (if CA is not the administrator)
_________________
19. Has the continuant been approved for an additional 11-month disability extension?
No
Yes
20. At the time of the separation or reduction in hours was the employee eligible to receive Social Security income?
No
Yes
21. Form Complete by:
Date:
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