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2024 COBRA Enrollment Form 2024 COBRA Enrollment Form-2026
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- Click ‘Get Form’ to open the 2024 COBRA Enrollment Form in the editor.
- Begin by filling out the personal data section. Clearly print your name, address, and contact information. Ensure all fields are completed accurately.
- Next, provide details for the COBRA policy holder and any former dependents. Include their names, social security numbers, and dates of birth as required.
- In the status & enrollment/change action requested section, indicate your qualifying event date and whether you are on Medicare. Select any changes in family status if applicable.
- Complete the dependent information section by listing all eligible dependents. Attach necessary documentation for any additions or removals.
- Finally, review your entries for accuracy before signing at the bottom of the form. Submit it via email or regular mail as instructed.
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Related links
If you choose to elect COBRA continuation coverage, you should use the election form provided later in this notice.
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COBRA enrollment must be completed within 60 days of your last day of coverage. You may stay enrolled in COBRA for up to 18 months continuously. Please keep aRead more