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Run: COBRA Election Form

Help employees or qualified beneficiaries elect COBRA continuation coverage after a qualifying event, with clear fields for coverage choice, dependents, prem...

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Participant Information

Full Name (required)

Mailing Address (required)

Phone Number (required)

Email Address (required)

Qualifying Event Details

Qualifying Event Type (required)

Date of Qualifying Event (required)

Current Coverage End Date (required)

The date your active group health coverage ended or will end.

Employer Name (required)

Coverage Election

COBRA Coverage Election (required)

Coverage Type (required)

Covered Dependents to Include

List any dependents you want included in the election, if applicable.

Requested Coverage Effective Date (required)

Typically the day after active coverage ends, based on plan rules.

Premium Acknowledgment

Premium Responsibility Acknowledgment (required)

Yes No N/A

Preferred Payment Method (required)

Questions or Comments About Premiums

Certification and Signature

Certification Statement

By signing below, I certify that the information provided is true and complete to the best of my knowledge.

Electronic Signature (required)

Signature Date (required)

Get your results

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Email (required)

Your name (optional)

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