The COBRA Continuation Coverage Election is a ready-to-use employment & hr template you can send for signature in minutes. It is written for 1 signer (beneficiary) and, by default, expires 30 days after it is sent if left unsigned. It covers healthcare. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
Document Preview
# 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:** ___________