Acknowledgement Of Receipt Of Cobra Rights Form
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1ACKNOWLEDGEMENT OF RECEIPT OF COBRA RIGHTS
I hereby acknowledge that I have received notice of rights to continue health plan
coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
I understand that I (and/or my spouse and dependent children) must complete and
submit the attached COBRA Election Form within 60 days of (1) the date of this
notice or (2) the loss of coverage (whichever is later) in order to be considered for
continuation of coverage. I further understand that all costs of continuation coverage will
be at my expense.
Print Name _______________________________________
Date ____________________
Signature _________________________________________
If any of the individuals entitled to coverage under your plan do not reside at your
address, please list those individuals and their current address(es) below so they may
receive notification of their COBRA rights as soon as possible. Attach a separate page
with additional names and addresses if necessary.
Name ___________________________________________________
Address:
_____________________________________________________________________________________________________
Street
City
State
Zip
Name ___________________________________________________
Address:
_____________________________________________________________________________________________________
Street
City
State
Zip
Direct questions and return this form to:
_________________________________
Representative
_________________________________
Company Name
_________________________________
Address
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