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California blue cobra 2026
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- Click ‘Get Form’ to open the California Blue COBRA application in the editor.
- Begin by entering your personal information in the 'Employee Information' section. Fill in your last name, first name, Social Security number, and Blue Shield ID number.
- Indicate the date of your qualifying event and select the appropriate option for the type of qualifying event from the provided checkboxes.
- Complete the section for the covered member who qualifies for COBRA. This includes their Social Security number, Blue Shield ID number, last name, first name, address, phone number, date of birth, sex, and marital status.
- If applicable, provide details about your Personal Physician and existing coverage you wish to continue by filling in the relevant fields.
- List all dependents eligible for coverage under COBRA. Ensure that only those previously enrolled on the group plan are included.
- Finally, review all entered information for accuracy before signing and dating the form at the bottom.
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Related links
UC Blue Gold HMO (3) 1,189.67 *The CalCOBRA extension which allows qualified beneficiaries to extend their medical plan coverage for up to a maximum of 36
Mar 12, 2026 On a blue gradient background, the word CALIFORNIA in blue fades and zooms in, and a blue curved filmstrip appears while flashing.