Continuation Of Coverage Election Form printable pdf download

COBRA CONTINUATION OF

COVERAGE ELECTION FORM

Employer _______________________________

Group Policy#_____________________

Persons Electing to Continue Coverage

Date of Birth

SSN

Employee ___________________________________________ _____________

____________

Spouse or Former Spouse______________________________

____________

Child(ren) ___________________________________________

____________

____________________________________________ _____________

____________

Address_____________________________________________________________________________

Qualifying Event

(Check all that apply)

Termination or reduction of hours worked

_________________________________________

Employees Entitlement to Medicare

_________________________________________

Dependent No Longer Eligible

_________________________________________

Divorce _______________

Employee’s Death ______________

EMPLOYER: This is to inform you that I wish to continue my: Dental ____________, Vision __________,

and/or Unreimbursed Medical _________ coverage(s). I have enclosed my monthly premium or will

forward the premium to you within 45 days. I understand that I must pay such premiums on a monthly

basis by (date) ________________, or my coverage(s) will be terminated. I also understand that I am

entitled to a grace period of at least 30 days.

I understand that I am not eligible for continuation of coverage if I am covered under any other group

health plan or eligible for medicare, whether by virtue of my employment or my spouse’s. My eligibility for

COBRA coverage will terminate on the date I am covered by any other group plan or become eligible for

Medicare. If the other group plan I am covered under does not cover a preexisting condition that applies

to me or my dependents, I understand that I may continue my coverage to cover that condition only.*

Are you covered by any other group health plan? Yes __________ No ___________

*If yes, do you have a preexisting condition? ______________________________________________

Signature of Employee ________________________________________ Date __________________

Signature of Spouse or Former Spouse ___________________________ Date __________________

Signature of Child Over 18 _____________________________________ Date __________________

_____________________________________ Date __________________

Sept 2007

Continuation Of Coverage Election Form