Hc-0807-1012 - State of New Jersey-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'To the Family of' section with the name of the employee or dependent. Ensure accuracy as this is crucial for processing.
3. Enter the Notice Date and Employer Name in their respective fields. This information helps identify the context of the COBRA notice.
4. Complete the Employee ID and type (10 month or 12 month) as applicable. This section is essential for categorizing employment status.
5. In the COBRA EVENT section, check the appropriate box that corresponds to your situation, such as termination or divorce.
6. Fill in CURRENT COVERAGE TYPE by selecting from options like Medical Plan and Prescription Drug Plan. Be sure to indicate your choice clearly.
7. Finally, review all entered information for accuracy before signing at the bottom. Make sure to keep a copy for your records.

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