Sample Cobra Insurance Form

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Sample cobra insurance form. The gov means it s official. If group health coverage was lost because of the death of the employee divorce legal separation medicare entitlement or a dependent child ceasing to be a dependent child under name of group health plan then the continuation coverage period is 36 months from the date of the qualifying. This notice is intended to inform you of your rights and obligations under the continuation of coverage provisions of the law. 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.

This continued coverage is provided by the consolidated omnibus budget reconciliation act cobra a federal law enacted on april 7 1976. 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. A small employer that uses properly completes and timely issues the department s form is presumed to satisfy notification requirements. Duration of cobra coverage other qualifying events.

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. Cobra general application use this form to apply for cobra health insurance benefits if your coverage is terminated on or after june 1 2020. 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. Federal government websites often end in gov or mil.