Templates › Forms › SEO page

Run: COBRA Election Form

COBRA Election Form for collecting a beneficiary’s coverage choice, dependent selections, and requested effective date after a qualifying event. Use it to do...

Fill this out, get a PDF emailed to you. No account required. Want to run it with your team and track results? Sign up free →

Participant Information

Participant Full Name (required)

Relationship to Employee (required)

Preferred Contact Email (required)

Preferred Contact Phone

Qualifying Event Details

Qualifying Event Type (required)

Date of Qualifying Event (required)

Current Coverage End Date (required)

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? (required)

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. (required)

Yes No N/A

Preferred Payment Method

Questions or Notes

Effective Date and Certification

Requested Effective Date (required)

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. (required)

Yes No N/A

Signature (required)

Date Signed (required)

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Generated with MangoApps Templates — browse 250+ free