Fill and Sign the Cobra Letter Form

SAMPLE COBRA ENROLLMENT &/OR WAIVER LETTER (on company letterhead) Date:       Enrollment deadline:       Employee name:       Enrolled dependents: Yes No Address:       City:       State, zip:       You have the right to continue certain covered benefits for yourself and your currently covered dependents. At this time I, the Principle Qualified Beneficiary, elect coverage for myself only Cost per month       elect coverage for my dependents only Cost per month       elect coverage for my family Cost per month       decline coverage If you elect coverage you are responsible for paying for your coverage on a monthly basis. You have 45 days in which to make your first payment and a 30-day grace period for each subsequent month. However, if you do not make payment in a timely manner as outlined your coverage will be terminated. If you waive coverage, you understand that at the end of the election period, as noted above, that your decision (their) will be final and irrevocable. Signature of employee Date ____ Signature of spouse (or other dependent over age 18) Date