Cobra Medical/dental/vision Benefits Election Form
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COBRA Medical/Dental/Vision Benefits Election Form
Subject to the terms stated in your Summary Plan Description, COBRA medical, dental, or vision benefits may be available for you and/or your
covered dependents. Please refer to the Summary Plan Description for terms and limitations. To apply for COBRA medical, dental, or vision benefits,
please complete and return this form to your employer (or previous employer, in the event of termination of employment) or the employer’s
COBRA administrator.
Employer name
Group number
Employee information
Employee name
Social Security number
Phone
Street address
Apt / Suite / PO box number
City
State
Zip code
Dependent information
Dependent name
Social Security number
Qualifying Event
Check the qualifying event that applies to you and indicate the date of the qualifying event in the blank
m
Termination
Last date employed _________________
m
Marriage
Date of marriage __________________
Date covered by Medicare ____________
Date hours reduced ________________
m
Medicare
m
Reduced Hours
m
Legal Separation
Date legal separation filed ____________
m
Employee’s Death
Date of death ____________________
Dependent Child
Date dependent child ceased
Divorce
Date divorce effective ______________
m
m
to be eligible dependent ______________
Date of active duty ________________
m
Reservist
Employer complete premium due for coverages. Date form is given to insured _______________
Medical
Dental
Vision
m
Individual only
_______ /Month
m
Individual only
_______ /Month
m
Individual only
_______ /Month
Individual and spouse _______ /Month
Individual and spouse _______ /Month
Individual and spouse _______ /Month
m
m
m
_______ /Month
_______ /Month
_______ /Month
m
Individual and child
m
Individual and child
m
Individual and child
m
Family
_______ /Month
m
Family
_______ /Month
m
Family
_______ /Month
(Note: Rates are subject to any employer changes to plan.)
PREMIUMS MUST BE PAID TO THE EMPLOYER OR THE COBRA ADMINISTRATOR SELECTED BY YOUR EMPLOYER.
The initial premium is due within 45 days after the date COBRA is elected. Subsequent premiums are due monthly by the first of the month. Payment
is considered timely if made within 31 days of the first of the month due date. Failure to submit a COBRA premium payment to the employer, or the
employer’s COBRA administrator, within the 31 day payment grace period will result in cancellation of coverage.
Signature of Person Electing or Waiving COBRA
m I elect COBRA
m I am waiving my right to COBRA
Employee signature ______________________________________________________________
Date _______________________
Spouse signature ________________________________________________________________
Date _______________________
Dependent signature _____________________________________________________________
Date _______________________
(If Over Age 19)
SPOUSE AND DEPENDENT SIGNATURES ARE REQUIRED IF ANY DEPENDENT COVERAGE IS BEING WAIVED.
This form must be completed and returned within 60 days after or the later of: 1) the date that you would lose coverage, or 2) the date that you are
sent notice of your right to elect COBRA. An election is considered to be made on the date that it is sent to your employer or plan sponsor. Failure to
return this form within the specified time may result in the loss of COBRA privilege.
NOTE: If you are deemed Totally Disabled by the Social Security Administration prior to,
or within 60 days of your COBRA election, you may be eligible to receive an additional
11 months of COBRA for you and your insured dependents. Please enclose your SSA
Notice of Award with this application or within 60 days of receipt of your award notice.
Reorder# GN-00517-HH 10/2007
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