Cobra Active/pending Takeover Form
ADVERTISEMENT
1Benecom Company
Third Party Administrators
3429 Stony Spring Circle
Louisville, KY 40220
(502)499-2501
(888)739-8587
◆
Fax (502)495-6825
Email:
COBRA
◆
Active/Pending Takeover Form
Participant Personal Information
Participant was an employee
Participant was a dependant
Name
: ______________________________________________________
Social Security Number: ________—________—_________
Address: ____________________________________________________
City, State, Zip _____________________________________
Telephone: (
) _________________________________
Date of Birth ____/____/_______
Date of Hire ____/____/_______
Qualifying Event: Terminated
Reduction of Hours
Quit
Retired Other: _______________________________
Qualifying Event Date: ____/____/_______ Loss of Coverage Date: ____/____/_______
Eligible for / Receiving AARA Subsidy Reduction: YES
NO If NO explain ______________________________________
Active COBRA :
Elected Coverage on ____/____/_______ and payment has been paid thru ____/____/_______
Elected COBRA:
Notice was sent on ____/____/_______ and Elected Coverage on ____/____/_______
Pending COBRA:
Notice was sent on ____/____/_______
Dependant Information
Name
: _______________________________________
Relationship: __________________
Date of Birth ___________________
Address: ____________________________________________________
City, State, Zip _____________________________________
Medical: Yes
No
Dental: Yes
No
Vision: Yes
No
Name
: _______________________________________
Relationship: __________________
Date of Birth ___________________
Address: ____________________________________________________
City, State, Zip _____________________________________
Medical: Yes
No
Dental: Yes
No
Vision: Yes
No
Name
: _______________________________________
Relationship: __________________
Date of Birth ___________________
Address: ____________________________________________________
City, State, Zip _____________________________________
Medical: Yes
No
Dental: Yes
No
Vision: Yes
No
Plan Information
Health
Dental
Vision
Previous Carrier
Employee Only
Employee Only
Employee Only
Carrier Name
Medical
__________________
Employee + Spouse
Employee + One
Employee + One
Dental
__________________
Employee + Child(ren)
Family
Family
Vision
__________________
Family
Company Name: _____________________________________________________
Date: ________________________________
Employer Representative Signature: ___________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business