COBRA or State Continuation of Coverage Application - Anthem 2026

1. Click ‘Get Form’ to open the COBRA or State Continuation of Coverage Application in the editor.
2. Begin by filling in your Employee Member Number, Health Group Number, Dental Group Number, and Vision Group Number at the top of the form. Ensure accuracy as these details are crucial for processing your application.
3. In the section labeled 'TO BE COMPLETED BY EMPLOYER ONLY', provide your Employer's name and your full name (First, Middle Initial, Last). This identifies you within the employer's records.
4. Indicate your Date of Hire and complete any relevant sections regarding your last day worked and last day of group coverage. This information is essential for determining eligibility.
5. Select the qualifying event that applies to you from the list provided. This could include termination of employment or a reduction in hours. Be sure to check all applicable events for yourself and dependents.
6. List individuals to be covered under continuation along with their relationship to you, birthdates, and coverage type desired (Medical, Dental, Vision).
7. Finally, review all entries for accuracy before signing and dating the application at the bottom. Your signature confirms that you agree to all terms outlined in the document.

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