Continuation Of Health Insurance Per The Consolidated Omnibus Budget Reconciliation Act (Cobra) Form - Dekalb County
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1DEKALB COUNTY GOVERNMENT
CONTINUATION OF HEALTH INSURANCE PER THE
CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA)
NAME:______________________________
DEPT:____________________
SOCIAL SECURITY NO:___________________
I understand that my health insurance coverage with DeKalb County Government is
scheduled to end as of ____________. I also understand that under the provisions of the
Consolidated Omnibus Budget Reconciliation Act (COBRA) I am eligible for the following
continuation coverage:
_______ single coverage
or
_______ family coverage
for a period of ____ up to 18 mo (final date of eligibility _________)
____ up to 29 mo (final date of eligibility _________)
____ up to 36 mo (final date of eligibility _________)
____ until the end of the disability period
____ until the end of the retirement period
and I understand that the cost will be $__________ per month (subject to change) which I
must pay prior to the first of each month. If I choose continuation coverage, the first month
for which payment will be due is ________________. Payments should be mailed or
delivered to:
DeKalb County Finance Office
200 N. Main St.
Sycamore, IL 60178
Please check one of the following:
_______
No, I do not wish to exercise my rights to continued health insurance
coverage and coverage will end as outlined above.
_______
Yes, I would like to extend my health insurance benefits as outlined above.
_______
I have not yet decided if I wish to continue my health insurance benefits as
outlined above; but if I do, I realize that I must notify the Finance Office in
writing of that election on or before _________________ (60 days from loss
of coverage).
I understand that no county employee is authorized to make any exception or
discretionary decision regarding the COBRA law.
_____________________________________
____________________
Employee Signature
Date
_____________________________________
____________________
Finance Representative Signature
Date
COBRA FORM.DOC
REV: 03/03
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