Certification of Previous Healthcare Coverage. Certification of Previous Healthcare Coverage 2026

1. Click ‘Get Form’ to open the Certification of Previous Healthcare 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 Month/Day/Year format.
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 as the employee. Ensure all information is accurate before submission.
8. If necessary, have your employer or COBRA administrator complete their section, including their signature and contact details.

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