Cobra continuation election form - Hollister Benefits Company: Fill out & sign online

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Click ‘Get Form’ to open the Cobra continuation election form in the editor.
Begin by indicating your desire to continue coverage under the Hollister Benefits Company Employee Benefit Plan. Select 'YES' or 'NO' and attach a new application if you choose 'YES'.
Fill in the effective date of your continuation coverage and indicate whether your first payment is enclosed by selecting 'YES' or 'NO'. Remember, if the first payment is not included, access to health care coverage may be delayed.
Select your qualifying event from the options provided: Termination, Death, Reduction in hours, Divorce, or Other.
Choose the type of insurance you wish to continue: Health, Dental, or Vision. Note that additional lines of insurance can only be added during Open Enrollment.
Indicate the type of coverage selected: Individual, Husband/Wife, Parent/Child, or Family. Keep in mind that dependents cannot be added until Open Enrollment unless there is a change in family status.
Sign and date the form. Print your name and provide your Social Security Number. If required, have a witness sign as well.

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