Consolidated Omnibus Budget Reconciliation Act "COBRA" PERS-HBD-85 (Rev 10/17). Consolidated Omnibus Budget Reconciliation Act "COBRA" PERS-HBD-85 (Rev 10/17) 2026

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Consolidated Omnibus Budget Reconciliation Act "COBRA" PERS-HBD-85 (Rev 10/17). Consolidated Omnibus Budget Reconciliation Act "COBRA" PERS-HBD-85 (Rev 10/17) Preview on Page 1

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  1. Click ‘Get Form’ to open it in the editor.
  2. In Part A, select the type of action: check 'NEW' for a new enrollment or 'CHANGE' if you are modifying existing coverage. Specify the qualifying event and its date.
  3. In Part B, fill in the COBRA enrollee's information, including name, address, and social security number. If applicable, identify the subscriber.
  4. Part C requires you to provide the name and address of your health plan. Ensure that you continue with the same coverage as before unless changing during Open Enrollment.
  5. In Part D, list all family members to be enrolled. Use action codes 'A' for adding and 'D' for deleting individuals from coverage.
  6. Complete Part F by signing and dating the form to confirm your agreement to pay premiums directly to the carrier.
  7. Finally, ensure that Parts G is filled out by your agency's health benefits officer after submission.

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