Model Cobra Continuation Coverage Election Notice (Page 3 of 8) in pdf

Model Cobra Continuation Coverage Election Notice Page 3

COBRA Continuation Coverage Election Form

Instructions

To elect COBRA continuation coverage, complete this Election Form and return it to

us. Under federal law, you must have 60 days after the date of this notice to decide whether you want

to elect COBRA continuation coverage under the Plan.

Send completed Election Form to: [Enter Name and Address]

This Election Form must be completed and returned by mail [or describe other means of submission and

due date]. If mailed, it must be post-marked no later than [enter date].

If you do not submit a completed Election Form by the due date shown above, you will lose your right

to elect COBRA continuation coverage. If you reject COBRA continuation coverage before the due

date, you may change your mind as long as you furnish a completed Election Form before the due date.

However, if you change your mind after first rejecting COBRA continuation coverage, your COBRA

continuation coverage will begin on the date you furnish the completed Election Form.

Read the important information about your rights included in the pages after the Election Form.

I (We) elect COBRA continuation coverage in the [enter name of plan] (the Plan) as indicated

below:

Name

Date of Birth

Relationship to Employee

SSN (or other identifier)

a. _________________________________________________________________________

[Add if appropriate: Coverage option elected: _______________________________]

b. _________________________________________________________________________

[Add if appropriate: Coverage option elected: _______________________________]

c. _________________________________________________________________________

[Add if appropriate: Coverage option elected: _______________________________]

_____________________________________

_____________________________

Signature

Date

______________________________________

_____________________________

Print Name

Relationship to individual(s) listed above

______________________________________

______________________________

Print Address

Telephone number

Model Cobra Continuation Coverage Election Notice Page 3