Ut 116c 2026

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cobra employee health insurance Preview on Page 1

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  1. Click ‘Get Form’ to open the ut 116c in the editor.
  2. Begin by filling in the 'General Information' section. Enter the Policy Holder Name and SS# accurately, followed by the Insurance Plan Name and Policy #.
  3. Answer the eligibility questions regarding COBRA coverage. Ensure to provide explanations where necessary, especially if any answers are 'No'.
  4. In the 'COBRA Plan' section, indicate when coverage began and complete the premium charts for different coverage types (Employee, Employee + spouse, etc.).
  5. Proceed to 'Policy Holder’s Health Plan Choice'. Answer questions about deductibles and benefits covered under the selected plan.
  6. Finally, sign and date the form in the 'Signature' section. Ensure that all information is accurate before submitting.

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