Cobra Election Form - Mba/biaw/nmta/camps Health Insurance Trust printable pdf download

MBA/BIAW/NMTA/CAMPS HEALTH INSURANCE TRUST

Continuation Coverage (COBRA) Election Form

A. Employee / Employer Information:

Employee Name: _______________________________

(Former) Employer: _____________________________

(Please print - last name, fi rst name, middle initial)

Employee Date of Birth: __________________________

Employer Group #: ____________________________

For Disabled and/or Over age 65 applicants:

Is applicant “entitled” to Medicare benefi ts? Yes

Employee Social Security #: ____________________

If “Yes”, indicate date of Medicare Entitlement: _____________

B. Qualifying Event / Type of Coverage:

1. Indicate which QUALIFYING EVENT caused

Continue coverage for (check only one box):

applicant’s Loss of Coverage:

Employee Only

Termination of employment/reduction in hours

Dependent(s) Only

Employee & Dependents

Death of Employee

Divorce

Dependent Child no longer eligible

Other (explain) __________________________

Note: Life and AD&D insurance coverages are not included under

Continuation Coverage.

2. Date of Qualifying Event: ____________________

3. Last date of coverage

____________________

4. Indicate type of Continuation Coverage requested:

C. Applicant Information:

(Applicant is Employee unless B.4.b “Dependent Only” Continuation Coverage is elected)

1. Applicant’s Name: ______________________________________

2. Social Security #: ____________________

(Please print - last name, fi rst name, middle initial)

3. Address: _____________________________________________

4. Applicant’s Birthdate: ___________________

______________________________________________

5. Telephone #: _______________________

(City)

(State)

(Zip)

(Monthly billing statement and all correspondence will be sent to this address)

6. List all Dependents for whom Continuation Coverage is elected: (continue on additional page if necessary)

Name of Dependent

Social Security #

Date of Birth

Relationship to Employee

___________________________________

_____________________

_______________

__________________________

___________________________________

_____________________

_______________

__________________________

___________________________________

_____________________

_______________

__________________________

D. Terms and Conditions:

Note: application will not be processed until payment is received

I elect Continuation Coverage on the applicant and dependents (if any) listed above in accordance with the Continuation Coverage terms and condi-

tions listed on the back of this form. I agree to make retroactive rate payment within 45 days of the date of this election for all months outstanding since

my employer sponsored coverage ended. I agree to make future rate payments in full within the time frames specifi ed on the back of this form. I have

read, understand and agree to the Continuation Coverage provisions set forth on the back of this form:

Applicant’s Signature: ______________________________________

Date: ___________________________

Return this Form and Payment To:

Administrator’s Use Only

EPK & Associates, Inc.

COBRA No: ___________________ Cov. _______________

15375 SE 30th PL. #380; Bellevue, WA 98007

Eff ective Date: _____________________________________

11/16

Cobra Election Form - Mba/biaw/nmta/camps Health Insurance Trust

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