COBRA Election Form

Form for employees or qualified beneficiaries to elect COBRA continuation coverage after a qualifying event, including coverage period, premium selection, and effective date details.

Participant Information

• Full Name
• Relationship to Employee
• Employee ID or Member ID
  Enter the employee or benefits identifier used by HR/benefits administration.
• Email Address
• Phone Number

Qualifying Event Details

• Qualifying Event Type
• Date of Qualifying Event
• Current Coverage End Date
  Enter the date current group coverage ends, if different from the qualifying event date.
• Additional Event Details
  Provide brief details only if needed to support eligibility review.

Coverage Election

• Coverage Election
• Coverage Types to Continue
• Covered Individuals Electing Coverage
• Requested Coverage Start Date
  If known, enter the requested effective date for continuation coverage.

Premium Selection and Payment

• Preferred Premium Payment Method
• Billing Address
  Provide a mailing address only if different from the contact address.
• I understand that COBRA premiums must be paid on time to maintain coverage.
• I understand that premium amounts, due dates, and grace periods will be provided by the plan administrator.

Effective Date and Certification

• Requested Effective Date
  If applicable, enter the date you want COBRA coverage to begin based on plan rules.
• I certify that the information provided is true and complete to the best of my knowledge.
• I consent to the use of my personal information for COBRA eligibility review, coverage administration, and audit trail purposes.
• Signature
• Submission Date