Cobra Election Form printable pdf download

Cobra Election Form

COBRA ELECTION FORM

To be completed by Employee/Applicant (Please Print)

EMPLOYEE NAME ____________________________________

S.S.#______/_____/_______

STREET ADDRESS ______________________________________________ APT # _________

CITY __________________________________ STATE _______ ZIP CODE _______________

PHONE: WORK (

)_____________________ HOME (

) ______________________

INDICATE QUALIFYING EVENT:

DATE OF QUALIFYING EVENT ______/______/________

____ Termination of Employment

____ Divorce or Legal Separation

____ Reduction in Work Hours

____ Medicare Eligibility

____ Death of Employee

____ Termination of Dependent Eligibility

EMPLOYEE SIGNATURE ________________________________________________________

INDICATE COVERAGE SELECTION:

Medical Coverage

___ I (We) elect NOT to continue coverage under the Group Medical Plan for:

___ Myself

___ My Spouse

___ My Dependent(s)

___ I (We) elect to CONTINUE coverage under the Group Medical Plan for:

___ Myself

___ My Spouse

___ My Dependent(s)

Dental Coverage

___ I (We) elect NOT to continue coverage under the Group Dental Plan for:

___ Myself

___ My Spouse

___ My Dependent(s)

___ I (We) elect to CONTINUE coverage under the Group Dental Plan for:

___ Myself

___ My Spouse

___ My Dependent(s)

Spouse's Name _________________ S.S.# _______/_____/_______ DOB _____/_____/______

Spouse's Street Address _________________________________________________________

City _________________________________________ State _______ Zip Code ___________

Dependent(s):

(The Employee or Spouse MUST complete for all minors)

Dependent Name ________________________S.S.# ____/_____/_____ DOB ____/____/_____

Cobra Election Form