COBRA Continuation Coverage
Please
complete and return this form to:
{Plan
Administrator}
{Employer
Name}
{Address}
{City, Zip}
Phone:
{Telephone} Â Â
Fax: {Fax}
Email: {Email}
|
Qualifying
Event: |
|
Date of
Event: |
|
Employee
Name: |
|
Home
Address: |
|
Social Security
Number: |
|
Job
Title: |
|
Department: |
Coverage
Categories
?
Decline
coverage (sign and return form)
?
Employee
coverage only (complete and return form)
?
Employee
and dependent coverage (list dependents below, complete and return form)
?
Dependent
coverage only (list dependents below and complete and return form)
Dependents and Relationship:
_____________________________________________ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â
_____________________________________________ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â
_____________________________________________ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â
_____________________________________________ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â
_____________________________________________ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â
_____________________________________________ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â
Coverage Options and Initial Monthly Payments:
Select the coverage you qualify for and will be
continuing. Â Transfer those coverage
amounts onto Table 2, and then total the monthly premium for the coverage you
have chosen.
|
COBRA Monthly Rates {YEAR} |
|
||||
|
|
{Carrier} |
{Carrier} |
{Carrier} |
{Carrier} |
{Carrier} |
|
|
{Plan Option} |
{Plan Option} |
{Plan Option} |
{Plan Option} |
{Plan Option} |
|
Employee |
|
|
|
|
|
|
Employee + Spouse |
|
|
|
|
|
|
Employee + Child |
|
|
|
|
|
|
Family |
|
|
|
|
|
|
Payment Amounts (Based on coverage options and premiums) |
|
|
Coverage |
Monthly Premium |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Total Monthly Standard Payment |
|
|
Pro-rated Payment* (payment for remainder of month of termination) |
|
|
Total First Payment |
|
* Is equal to: (monthly total divided by 31) x the number of
days remaining in month
Employee´s first payment should be received no more than 45 days from the date the employee signs this form. Â The first payment is retroactive, meaning it must include the period between the loss of group health plan coverage and the date of the signing of this form. Â All subsequent payments are due on {ENTER DATE}.
I have read and understood this form and the accompanying letter, and I understand my rights to elect continuation coverage and the payments I will be responsible for.
________________________ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â
Employee Signature
________________________
Date
________________________ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â
Dependent Signature
(other than minor)
________________________
Date