COBRA Continuation Coverage Election Form

COBRA CONTINUATION COVERAGE ELECTION FORM

Employer / Plan Information

Employee / Qualified Beneficiary Information

Employee Name:

Last 4 digits of SSN:    Date of Birth:

Employment / Event Details

Job Title:    Department:

Hire Date:    Last Day Worked / Date of Qualifying Event:

Involuntary termination (other than for gross misconduct)
Voluntary termination
Reduction in hours
Divorce or legal separation
Death of employee
Employee entitled to Medicare
Dependent ceasing to be eligible

Date of Qualifying Event (if different from last day worked):    Date Coverage Ended or Will End:

Election of Continuation Coverage

Check one option below to indicate election decision. I understand that I must make my election within the required election period specified by the plan.

I elect to continue coverage under the employer's group health plan pursuant to applicable continuation coverage rules. I understand premiums will be charged retroactively to the date of loss of coverage if required by the plan.
I decline continuation coverage under the employer's group health plan. I understand that by declining I forfeit the right to elect COBRA continuation for the period described by the plan and that this election is irrevocable for the period referred to.

Coverage Selected

Select the coverage(s) you elect to continue:
Medical
Dental
Vision
Other:

Dependents to Be Covered

List dependents you elect to continue (if any):

DOB:    Relationship:

DOB:    Relationship:

DOB:    Relationship:

Premiums & Payment

Monthly premium amount (per month for elected coverage):    Initial premium due by:

Check or money order
Credit/Debit Card (if accepted by plan administrator)
ACH / Electronic withdrawal

Important Notices, Acknowledgements and Certification

I understand that under the terms of the plan I have the right to elect continuation of group health coverage for myself and my eligible dependents for the time period permitted by the plan and applicable law. I further understand that:

(a) The election period is limited and that my election must be received within the time period established by the plan; failure to elect within that period will result in loss of the right to elect continuation coverage. The plan may require payment of any premiums owed retroactive to the date coverage was lost if this election is timely made.

(b) If I elect continuation coverage, I am responsible for timely payment of premiums, and failure to pay required premiums in accordance with the plan provisions will result in termination of continuation coverage as provided by the plan.

(c) Continuation coverage may be terminated earlier than the maximum period if the plan ceases to provide group health coverage to any active employees, if the required premium is not paid on time, if the individual becomes covered under another group plan that does not impose any preexisting condition exclusion affecting the individual, or if the individual becomes entitled to Medicare.

(d) I agree to notify the plan administrator of any address changes or changes in the status of any qualified beneficiaries who elect continuation coverage. I understand that failure to provide timely notice of changes may result in loss or delay of benefits.

(e) By signing below I certify under penalty of perjury that the information I have provided on this form is true and complete to the best of my knowledge. I authorize the plan administrator and employer to use and disclose the information supplied on this form as necessary to administer my continuation coverage election.

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