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

• Participant Full Name
• Relationship to Employee
• Preferred Contact Email
• Preferred Contact Phone

Qualifying Event Details

• Qualifying Event Type
• Date of Qualifying Event
• Current Coverage End Date
• Additional Event Details
  Provide only the details needed to process the election. Do not include sensitive personal information unless specifically requested by HR.

Coverage Election

• Do you want to elect COBRA continuation coverage?
• Coverage Types to Continue
• Covered Dependents to Include

Premium Acknowledgment

• I understand that I am responsible for paying the full COBRA premium, including any applicable administrative fee.
• Preferred Payment Method
• Questions or Notes

Effective Date and Certification

• Requested Effective Date
  If applicable, this should align with the COBRA election rules and HR guidance.
• I certify that the information provided is true and complete to the best of my knowledge.
• Signature
• Date Signed