Fill and Sign the Cobra Form

COBRA Continuation Coverage Election Form Instructions: To elect COBRA continuation coverage, complete this Election Form and return it to us. Under federal law, you must have 60 days after the date of this notice to decide whether you want to elect COBRA continuation coverage under the Plan. Send completed Election Form to: { Enter Name and Address } This Election Form must be completed and returned by mail { or describe other means of submission and date due }. If mailed, it must be post-marked no later than { Enter Date }. If you do not submit a completed Election Form by the due date shown above, you will lose your right to elect COBRA continuation coverage. If you reject COBRA continuation coverage before the due date, you may change your mind as long as you furnish a completed Election Form before the due date. However, if you change your mind after first rejecting COBRA continuation coverage, your COBRA continuation coverage will begin on the date you furnish the competed Election Form. Read the important information about your rights included in the pages after the Election Form. I (We) elect to continue our coverage in the { Enter Name of Plan }(the Plan) as indicated below: Name:       Date of Birth:       Relationship to Employee:       SSN (or other identifier):       Coverage option elected:       [Add if appropriate] Name:       Date of Birth:       Relationship to Employee:       SSN (or other identifier):       Coverage option elected:       [Add if appropriate] Name:       Date of Birth:       Relationship to Employee:       SSN (or other identifier):       Coverage option elected:       [Add if appropriate] Name:       Date of Birth:       Relationship to Employee:       SSN (or other identifier):       Coverage option elected:       [Add if appropriate] Name:       Date of Birth:       Relationship to Employee:       SSN (or other identifier):       Coverage option elected:       [Add if appropriate] Signature: ____________________________________________________________________ Print Name:       Relationship to individual(s) listed above:       Print Address:       Telephone Number: