Proof of loss of employment 2025

1. Click ‘Get Form’ to open the proof of loss of employment document in the editor.
2. Begin by entering your Social Security Number (SSN) in the designated field at the top of the form.
3. Fill in your full name, including first name, middle initial, and last name, ensuring accuracy for identification purposes.
4. Indicate your last day of health coverage by selecting the appropriate month, day, and year from the dropdown menus.
5. Check all applicable boxes under 'Whose coverage is ending' to specify whether it’s yours, your spouse’s, or dependent child(ren)’s coverage that is ending.
6. Select the reason for loss of coverage from the provided options. If 'Other' is selected, specify the reason in the space provided.
7. Attest to continuous coverage by checking all relevant boxes for health, dental, and vision coverage before signing at the bottom.
8. If required, have your employer or COBRA administrator complete the verification section to confirm previous healthcare coverage details.

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