Sample Cobra Health Insurance Form

Health benefits compliance assistance.

Sample cobra health insurance form. This continued coverage is provided by the consolidated omnibus budget reconciliation act cobra a federal law enacted on april 7 1976. Cobra model notice general. This notice is intended to inform you of your rights and obligations under the continuation of coverage provisions of the law. Delinquent filer voluntary compliance program dfvcp.

This notice must be sent to the plan participants and beneficiaries by first class mail or hand delivered not later than 14 days after the plan administrator receives notice that a qualifying event occurred. Cobra general notice gic enrollees receive this notice in their health plan handbook to advise them of their rights under cobra upon employment termination or family status changes. Forms can be customized and distributed to your employees. Street address street address city state and zip this notice contains important information about your right to continue your health care coverage in the abc company group health plan the plan.

Cobra continuation coverage election form. Cobra model notices for the american reinvestment and recovery act arra cobra model notice for the american reinvestment and recovery act arra. Pursuant to subsection c of the law the department has prepared a sample notice of coverage continuation form and is making the sample available on its website. Mental health and substance use disorder benefits.

Instead of enrolling in cobra continuation coverage there may be other more affordable coverage options for you and your family through the health insurance marketplace medicaid medicare or other group health plan coverage options such as a spouse s plan through what is called a special enrollment period. Cobra health continuation coverage. Cobra general application use this form to apply for cobra health insurance benefits if your coverage is terminated on or after june 1 2020. Sample cobra notice abc company c o the cobra administrator s name 1234 south st city state and zip 06 10 2008 pqb name.

If you or a family member recently left a job with group health insurance you may be able to continue this coverage by paying the full cost of the insurance. Children s health insurance program reauthorization act chipra retirement benefits.