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Home :: FAQ :: Cobra Coverage

What will my election form look like and what will it require of me?

To elect COBRA continuation coverage, an employee will complete an election form and any applicable carrier forms and return it to the employer’s benefits coordinator. Under federal law, you must have 60 days after the date of this notice to decide if you want to elect COBRA continuation coverage under the plan.

Your election form and carrier forms must be completed and returned by mail. It must be postmarked no later than 60 days after your termination of employment. Normally, one makes checks payable to the benefits coordinator and should include the participant’s SSN/Part, ID on the check.

If you do not submit a completed election form by the due date required, you will lose your right to elect COBRA continuation coverage. If you reject COBRA continuation coverage before the due date, you may change your mind as long as you furnish a completed election form before the due date. However, if you change your mind after first rejecting COBRA continuation coverage, your COBRA continuation coverage will begin on the date you furnish the completed election form.

Normally, your election form will appear like the following example:

I (we) elect COBRA continuation coverage in the plan as indicated below:


Qualified Beneficiary

Date Of Birth

Sex

Relationship to Employee

SSN/Part ID

Name

 

 

 

 

a. ____________

________

________

_______________

__________

b. ____________

________

________

_______________

__________

c. ____________

________

________

_______________

__________

d. ____________

________

________

_______________

__________

Refer to the “Applicable Coverage/Rates” page to list below the benefits that you wish to elect under COBRA.


Coverage

Plan

Enrollment Level

Monthly Rate

 

 

 

 

____________________

______________

______________

________________

____________________

______________

______________

________________

____________________

______________

______________

________________

COVERAGE WILL NOT BE REINSTATED UNTIL THE COMPLETED FORM(S) AND INITIAL PAYMENT IS RECEIVED AND PROCESSED BY THE APPROPRIATE OFFICE.
To calculate the amount of your first check:
Month check is mailed:      Months you owe for:      Multiply monthly rate above by: