Cobra continuation coverage election form 2025

1. Click ‘Get Form’ to open the COBRA Continuation Coverage Election Form in the editor.
2. Begin by filling in your personal information. Enter your last name, first name, middle initial, date of birth, and social security number in the designated fields.
3. Indicate your relationship to the employee by selecting the appropriate option from the dropdown menu.
4. For each dependent, repeat step 2 and 3, ensuring all necessary details are accurately filled out for each individual covered under the plan.
5. Select the type of coverage you wish to elect by checking either 'family coverage' or 'single coverage'. If you choose to decline coverage, check the corresponding box.
6. Finally, sign and date the form. Ensure that your printed name and address are clearly written along with a contact telephone number.

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