Cobra form net 2026

1. Click ‘Get Form’ to open the COBRA election form in the editor.
2. Begin by entering your employer's name and group number at the top of the form. This information is essential for processing your election.
3. Fill in your personal details, including your name and Social Security number. Ensure accuracy to avoid any delays.
4. Indicate the type of qualifying event that led to your loss of coverage by checking the appropriate box. This could include termination of employment or reduction in hours.
5. Specify the date of the qualifying event. This date is crucial as it determines your eligibility period for COBRA continuation coverage.
6. Review the acknowledgment statement regarding your understanding of COBRA options and select whether you wish to continue coverage by checking 'Yes' or 'No'.
7. If electing coverage, choose which options you want (self only, family members, medical, dental) and sign and date the form at the bottom.
8. List all dependents you wish to cover, providing their names and Social Security numbers as required. If more space is needed, indicate that an additional page is attached.

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