Cobra appeal 2026

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4.8 out of 5

26 votes

The document outlines the process for appealing a termination of COBRA eligibility or enrollment. It details the steps to submit a written appeal to WageWorks, including deadlines, required information, and the review process. The appeal must be submitted within 180 days of notification of termination, and additional supporting documents can be included. A decision will be communicated in writing within 30 days.

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Click ‘Get Form’ to open the COBRA Appeal Form in the editor.
Begin by filling out the Participant Information section. Enter your name, former employer, participant ID number, email address, mailing address, city, state, zip code, and telephone number.
In the Appeal Information section, provide the COBRA termination date and reason. Clearly state your reason for appeal and indicate if you are filing on behalf of yourself, spouse, child, or other dependents.
List all payments made for COBRA coverage along with their dates and amounts in the Payments and Correspondence section. Also include any letters received regarding your COBRA coverage.
Review all entered information for accuracy. Once complete, sign and date the form before submitting it via mail or fax to WageWorks.

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Versions	Form popularity	Fillable & printable
2013	4.8 Satisfied (26 Votes)

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