Cobra letter 2026

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The document is a COBRA enrollment and waiver letter that outlines an employee's rights to continue health benefits for themselves and their dependents. It includes options for electing or waiving coverage, payment responsibilities, deadlines, and the irrevocability of the decision to waive coverage.

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Click ‘Get Form’ to open the cobra letter in the editor.
Begin by entering the date at the top of the form, followed by the enrollment deadline.
Fill in your name as the employee and list any enrolled dependents in the designated fields.
Indicate your choice regarding coverage by selecting 'Yes' or 'No' for each option provided.
Complete your address details, including city, state, and zip code.
As the Principal Qualified Beneficiary, select one of the options regarding coverage: for yourself only, for dependents only, for family, or decline coverage.
Review and enter the cost per month for each selected coverage option.
Sign and date where indicated. If applicable, have your spouse or dependent over age 18 sign as well.

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