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After the COBRA election, coverage is obtained with another employer group health plan that does not contain any exclusion or limitation with respect to any pre-existing condition of such beneficiary. ... After the COBRA election, a beneficiary becomes entitled to Medicare benefits. However, if Medicare is obtained prior...
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www.dol.gov/ebsa/faqs/faq_consumer_cobra.HTML
www.dol.gov/ebsa/faqs/faq_consumer_cobra.HTML
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COBRA ELECTION / WAIVER FORM. TO BE COMPLETED BY EMPLOYER DATE: Name of Employee: Date of Last Day Worked: Date Election Period Expires (60 days from the ...
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www.ncbcapitalimpact.org/documents/aalmanual_COBRAelect...
www.ncbcapitalimpact.org/documents/aalmanual_COBRAelectn.doc
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Federal COBRA Forms; You will need to download and install Adobe Acrobat to view and print these forms. COBRA Statement; This statement is to be given to newly hired employees. Sample Notice and Election Form;
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www.ibpis.com/Html/cobrafrm.htm
www.ibpis.com/Html/cobrafrm.htm
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GROUP HEALTH CONTINUATION PLAN FOR MYSELF AND ELIGIBLE QUALIFIED; DEPENDENTS LISTED ON THIS FORM AND AGREE TO PAY THE PREMIUM AS REQUIRED.
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www.grouphealthplans.com/COBRAelection.html
www.grouphealthplans.com/COBRAelection.html
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Dependent child reaching maximum age for coverage - up to 36 months. Date child attains the age of 19, ceases to be a full-time student or attains the age ... ELECTION FORM FOR CONTINUATION OF BENEFITS (COBRA); THE PENNSYLVANIA STATE UNIVERSITY; Employee Benefits Division; 120 S. Burrowes Street; University Park, PA 16801...
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www.ohr.psu.edu/benefits/HealthPlans/forms/COBRA_Electi...
www.ohr.psu.edu/benefits/HealthPlans/forms/COBRA_Election_Form.htm
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PLEASE NOTE: This form is being provided by KPS Health Plans as a service to our members. KPS accepts no liability for the proper administration of COBRA on behalf of the employer. Please consult your employer’s Human Resources department or call the U.S. Department of Labor – EBSA at (206) 553-4244 for information.
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www.kpshealthplans.com/forms/cobraform.pdf
www.kpshealthplans.com/forms/cobraform.pdf
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COBRA CONTINUATION COVERAGE ELECTION FORM; INSTRUCTIONS: To elect COBRA continuation coverage, complete this Election Form and return it to us. Under federal law, you must have 60 days after the date of this notice to decide whether you want to elect COBRA continuation coverage under the Plan.
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www.ut.regence.com/docs/forms/electionNoticeAndFormCOBR...
www.ut.regence.com/docs/forms/electionNoticeAndFormCOBRA.pdf
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Please return this election within 60 days from qualifying event date to the address indicated below. If you elect coverage, separate enrollment documents must be completed for each benefit. The form(s) are ... ELECTION FORM FOR COBRA CONTINUATION COVERAGE ... ELECTION TO ENROLL IN OR DECLINE COBRA CONTINUATION COVERAGE:
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www.csusm.edu/HR/benefits/98.cobra.elect.form.dl.html
www.csusm.edu/HR/benefits/98.cobra.elect.form.dl.html
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I elect to continue group health coverage under COBRA legislation: YES NO ... List all individuals to be covered, including the policyholder (if applicable). Only individuals who are insured prior to the qualifying event are eligible for COBRA NAME BIRTHDATE SOCIAL SECURITY #
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www.scribd.com/doc/7785336/Firm-Name-Cobra-Election-For...
www.scribd.com/doc/7785336/Firm-Name-Cobra-Election-Form-Name-Address-I-Elect
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