Certification of Previous Health Care Coverage. Certification of Previous Health Care Coverage 2025

1. Click ‘Get Form’ to open the Certification of Previous Health Care Coverage in the editor.
2. Begin by entering your Employee Information. Fill in your Social Security Number (SSN), first name, middle initial (MI), and last name.
3. Indicate the Last Day of Prior Coverage by selecting the appropriate date using the date picker.
4. Check all applicable boxes under 'Coverage is ending for' to specify whether it applies to yourself, spouse, or dependent child(ren).
5. Select the reason for loss of coverage from the provided options, ensuring you check all that apply.
6. Attest to continuous coverage by checking the relevant boxes for health, dental, and vision coverage.
7. Sign and date the form in the Employee Signature section to certify that all information is accurate.
8. If necessary, have your employer or COBRA administrator complete their section with their signature, phone number, title, and date.

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