Employment & HR
COBRA Continuation Coverage Election
COBRA continuation coverage election form for health insurance continuation. 1 signer (beneficiary).
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# COBRA Continuation Coverage Election **Date:** ___________ This COBRA Continuation Coverage Election Form ("Election") is submitted by: **Qualified Beneficiary:** ___________ ("Beneficiary") ## 1. Former Employer Information **Employer Name:** ___________ **Employer Address:** ___________ **Plan Administrator Contact:** ___________ **Group Health Plan Name:** ___________ **Group Policy Number:** ___________ ## 2. Qualified Beneficiary Information **Address:** ___________ **Phone:** ___________ **Email:** ___________ **Date of Birth:** ___________ **Social Security Number (last 4 digits):** ___________ **Relationship to Covered Employee:** ___________ ## 3. Qualifying Event **Type of Qualifying Event:** ___________ **Date of Qualifying Event:** ___________
Fields (26)
effective date
date · required
beneficiary name
text · required
employer name
text · required
employer address
textarea · required
plan admin contact
text · required
plan name
text · required
group policy number
text · required
beneficiary address
textarea · required
beneficiary phone
text · required
beneficiary email
text · required
beneficiary dob
date · required
beneficiary ssn last4
text · required
relationship
select · required
qualifying event
select · required
event date
date · required
coverage loss date
date · required
coverage election
select · required
coverage type
select · required
dependents covered
select · required
dependent details
textarea
coverage end date
date · required
monthly premium
text · required
premium due
select · required
payment method
select · required
governing state
select · required
beneficiary signer name
text · required
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