Notice of Right to Elect State Continuation Coverage bTerminationb or bb 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date of notice at the top of the form. This is crucial for tracking your election period.
3. Fill in your personal information, including your name, address, and Social Security number in the Qualified Beneficiary Information section.
4. Indicate the qualifying event by checking either 'Termination of employment' or 'Reduction in hours of employment'.
5. Review the Length of Coverage section to understand that you are eligible for up to 6 months of continuation coverage.
6. Complete the Premiums section by selecting your desired coverage type and ensuring you understand payment timelines.
7. Sign and date the State Continuation Election Agreement, confirming your understanding of your rights and responsibilities.
8. Submit the completed form to your Plan Administrator as instructed at the bottom of the document.

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