Cal-Cobra Election Form - Blue Shield Of California

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Cal-COBRA Election Form
Please return completed form to: Blue Shield of California Cal-COBRA, PO Box 629009, El Dorado Hills, CA 95762-9009.
Blue Shield of California will accept those individuals already on Cal-COBRA coverage from a prior carrier. If an employer changes to a Blue Shield
health plan, you may continue Cal-COBRA coverage with Blue Shield for the duration of your Cal-COBRA coverage period based on your original
qualifying event.
I hereby elect Blue Shield of California subscriber coverage and/or family coverage for my eligible dependents listed below as may be contracted
for by the group contract holder. Blue Shield benefits, dues, and contract modifications will be in accordance with the group service contract and
as allowed under Cal-COBRA.
Employee information
Last name
First name
MI
Blue Shield of California ID/SSN
Group/section number
Date of original qualifying event
Original qualifying event
Check one, enter required date
c Termination or reduction in covered employee’s hours (last day worked) ______/______/______
c Divorce or legal separation of the covered employee (qualifying event date) ______/______/______
c Entitlement to Medicare benefits by covered employee (qualifying event date) ______/______/______
Covered employee name ___________________________________________________ Blue Shield of California ID/SSN ________________
c Disqualification of dependent child under the plan (qualifying event date) ______/______/______
c Termination or reduction of hours due to disability (last day worked) ______/______/______
c Death of covered employee (qualifying event date) ______/______/______
c Termination of domestic partnership (qualifying event date) ______/______/______
Qualifying elector information
Last name
First name
MI
Blue Shield ID/SSN
Address
Phone number
(street, city, state, ZIP)
(
)
Date of birth
Gender
Married?
Domestic partnership?
(month, day, year)
c Male c Female
c Yes
c No
c Yes
c No
Does qualifying elector have other health coverage?
Does qualifying elector have Medicare?
Does qualifying elector have Medicare due to disability?
c Yes
c No
c Yes
c No
c Yes
c No
If HMO, please indicate your
Phone number
Personal Physician’s name
(
)
Signature of elector
X ______________________________________________________________________________________ Date __________________
Please print signature name
X ____________________________________________________________________________________________________________
(see reverse)

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