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Ut 116c 2026
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- Click ‘Get Form’ to open the ut 116c in the editor.
- Begin by filling in the 'General Information' section. Enter the Policy Holder Name and SS# accurately, followed by the Insurance Plan Name and Policy #.
- Answer the eligibility questions regarding COBRA coverage. Ensure to provide explanations where necessary, especially if any answers are 'No'.
- In the 'COBRA Plan' section, indicate when coverage began and complete the premium charts for different coverage types (Employee, Employee + spouse, etc.).
- Proceed to 'Policy Holder’s Health Plan Choice'. Answer questions about deductibles and benefits covered under the selected plan.
- Finally, sign and date the form in the 'Signature' section. Ensure that all information is accurate before submitting.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2014 | 4.8 Satisfied (120 Votes) |
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ut 116c
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This form MUST be completed by your previous employer or your COBRA insurance company representative. please call 1-866-435-7414. 877-313-4717