Cobra Application Form
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1COBR
PPLIC TION
Please identify who collects COBRA
premiums:
LENGTH OF COVERAGE
PREMIUM
K
Delta Dental collects premiums
K
Group collects premiums
Delta Dental of New Jersey, Inc.
P.O. Box 219, Parsippany, NJ 07054
COBRA Inquiries: 973-285-4145
You may continue your dental care coverage by electing to do so and by paying the Total Monthly Contribution Payment. You have until the date 60 days after the
later of (a) the date of termination or (b) the date of notice to make that election and return the completed notice to your prior employer.
THIS SECTION TO BE COMPLETED BY GROUP ADMINISTRATOR
__________–__________
GROUP NUMBER
GROUP NAME
EFFECTIVE DATE OF COBRA COVERAGE
PLEASE INDICATE THE QUALIFYING EVENT BY CHECKING ONE OF THE FOLLOWING:
EMPLOYEE DEATH, employee member ID# _________________
K
K
DEPENDENT OF AN EMPLOYEE ELIGIBLE FOR MEDICARE,
employee member ID# _________________
K
EMPLOYEE MARRIAGE, DISSOLUTION OR LEGAL
SEPARATION, employee member ID# ______________
K
EMPLOYEE TERMINATION OF EMPLOYMENT OR REDUCTION IN WORK HOURS
K
RETIREE NOT ELIGIBLE FOR MEDICARE
CHILD NO LONGER AN ELIGIBLE DEPENDENT, covered
K
K
DISABLED INDIVIDUAL ELIGIBLE FOR 29 MONTHS OF COVERAGE
parent's member ID# _________________
Date
Signature of Group Representative (NOTE: APPLICATIONS CANNOT BE PROCESSED WITHOUT AUTHORIZED SIGNATURE)
THIS SECTION TO BE COMPLETED BY PERSON ELIGIBLE FOR CONTINUATION OF COVERAGE
MEMBER ID NUMBER
LAST NAME
FIRST
INITIAL
BIRTHDATE
MAILING ADDRESS:
Telephone: _______–_______–___________
DEPENDENTS TO BE COVERED:
MEMBER ID NUMBER
FIRST NAME
RELATIONSHIP
DATE OF BIRTH
_____________________________________
____________________________
_____ /_____ /_______
__________________________
_____________________________________
____________________________
_____ /_____ /_______
__________________________
_____________________________________
____________________________
_____ /_____ /_______
__________________________
_____________________________________
____________________________
_____ /_____ /_______
__________________________
K
K
Are you covered under any other dental program?
Yes
No
If YES, name and address of other carrier: __________________________________________________________________________________________
I hereby acknowledge receipt of the formal notification from my employer or group sponsor regarding my right to continuation of dental benefits under the
Consolidated Omnibus Budget Reconciliation Act of 1985 (P.L. 99-272), referred to as COBRA.
K
I do not wish to have my dental benefits continued. I fully understand that I hereby waive any right to rescind this at a later date and that my dental
coverage ceases under the terms of the master contract with Delta Dental of New Jersey, Inc.
K
I wish to continue my dental benefits as defined in the master contract with Delta Dental of New Jersey, Inc. and as provided under COBRA regulations.
I understand that the dental benefits could terminate in accordance with the COBRA regulations that were explained in the formal notification
mentioned above.
If I have elected to continue coverage under Delta Dental due to the Qualifying Event as indicated above, I understand that in order to retain coverage I must
meet the required payment obligations and/or such other conditions as may be required. Failure to do so will result in automatic termination of benefits.
Signature of Applicant
Date
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