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- Click ‘Get Form’ to open the COBRA Enrollment Form in the editor.
- Begin by completing the 'TO BE COMPLETED BY EMPLOYER' section. Ensure your former employer fills in their details, including the Purchaser/Enrollment Unit Number and Employer Signature/Date.
- In the 'Reason for COBRA Enrollment' section, check the appropriate box that corresponds to your situation. Fill in dates related to employment termination or loss of coverage as required.
- Proceed to 'Additional Enrollment Information' and indicate if any beneficiaries are disabled or if you are applying for a Health Care Tax Credit. Attach necessary documentation if applicable.
- Complete the 'TO BE COMPLETED BY EMPLOYEE' section by providing personal information such as name, Social Security number, date of birth, and contact details. Ensure all dependents are listed accurately.
- Review all entries for accuracy and completeness before signing the form. Remember that only dark blue or black ink should be used.
- Finally, confirm where to submit this form with your former employer and do not send payment with it.
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You have 60 days to enroll in COBRA, starting when your job-based coverage ends or when you receive a COBRA election notice--whichever is later. EnsuresRead more