Cobra enrollment form get 2026

1. Click ‘Get Form’ to open the COBRA Enrollment Form in the editor.
2. 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.
3. 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.
4. 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.
5. 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.
6. Review all entries for accuracy and completeness before signing the form. Remember that only dark blue or black ink should be used.
7. Finally, confirm where to submit this form with your former employer and do not send payment with it.

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