Continuation Of Coverage Form Qualifying Event - Florida Blue
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1Continuation of Coverage
QUALIFYING EVENT
RETURN TO: Florida Blue • P. O. Box 45272 • Jacksonville, Fl 32232-5272 • 1-855- 509-1678.
16) COBRA Qualifying Event that caused loss of coverage
PLEASE CHECK
ORIGINAL NOTICE
(check one)
Continuation of coverage for 18 months:
ONE BOX
REVISION to a form that was previously sent
Employee’s retirement
1) Group Employer Name
Employee’s reduction in hours
Employee’s resignation
Employee’s layoff
2) Group Account Number
Employee’s involuntary termination
Employee’s begins leave of absence
Continuation of coverage for 36 months:
3) Please be advised that the following has had a Qualifying Event.
(check one)
Divorce/legal separation
Ineligibility of dependent child
Employee
Dependent
Covered employee/retiree becomes entitled to Medicare effective
4) Social Security Number of Qualified Beneficiary
______________
date of Medicare entitlement
dependents may elect
________________________
continuance of coverage
Death of covered employee /retiree
5) Employee # (if applicable)
Retiree, spouse or child of retiree loses coverage within one
year before or after commencement of proceedings by sponsoring
employer under title 11 (bankruptcy) United States Code
(Code 7)
6) Qualified Employee Name
17) Spouse/Dependent Information.
Each name should include last, first and middle initial.
Name of Spouse_______________________________________________
____________________
Last, First, Middle
Social Security Number
_________________________
Date of Birth
Street (include apartment number)
Gender
Male
Female
City
State
Zip Code
Address
___________________________________
(if different from participant)
Dependent #1
7) Home Phone # of Qualified Beneficiary
(include Area Code)
Name of Dependent_______________________________________________
________________________
______________________
Social Security Number
___________________________
8) If the Qualified Beneficiary listed in box #6 is not the employee, enter
Date of Birth
Gender
Male
Female
_____________
the following: Employee SSN
Address
______________________________________
(if different from participant)
Dependent’s Relationship to Employee ___________________________
Dependent #2
Name of Dependent_______________________________________________
9) Date of Birth of Qualified Beneficiary
10) Gender
(check one)
______________________
_________________
Social Security Number
Male
Female
_________________________
Date of Birth
Gender
Male
Female
___________________
11) Qualifying Event Date
Address
______________________________________
(if different from participant)
Dependent #3
12) Benefit Termination Date
(cannot be prior to Qualifying Event Date)
Name of Dependent_______________________________________________
______________________________
______________________
Social Security Number
_________________________
Date of Birth
13) Is this a second Qualifying Event for a dependent who is currently
Gender
Male
Female
on COBRA?
No
Yes
Address
______________________________________
(if different from participant)
Dependent #4
14) If employee, does he/she have a health care FSA?
Name of Dependent_______________________________________________
______________________
No
Yes, MONTHLY contribution $_____________________
Social Security Number
_________________________
15) Enter the current Plan Number for the coverage(s) in effect on the day
Date of Birth
before the Qualifying Event Date:
Gender
Male
Female
Plan Number*
Plan Number*
Address
______________________________________
(if different from participant)
Medical ________________
Vision
________________
Prepared By
Dental _________________
Other
________________
Name: (PRINT)________________________________________________
____________________________
* Only applicable if - tells group/member dental/vision is only available if offered by the
Date:
group.
_________________________
Note: Domestic partners and their dependents are not considered COBRA qualified
Telephone #
beneficiaries. Please call us at 1- 800-876-2227 for plan options.
_____________________________
Fax #
Health coverage is offered by Blue Cross and Blue Shield of Florida, D/B/A Florida Blue. HMO coverage is offered by Health Options, Inc., D/B/A Florida Blue HMO,
an affiliate of Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.
81413-1014
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