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COBRA Election Form

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					A COBRA Election Form will allow an employee to continue its group health care
coverage on a temporary basis under the former employer's plan, if the employee’s
coverage would otherwise end due to termination or other change in employment
status. This form also covers any dependants of the employee. This document can be
customized to allow the employee’s unique information to be easily inserted into this
form. This document should be used by employers seeking to establish continuation
coverage under COBRA.
                                     COBRA Election Form

Instructions: To elect continuation coverage under COBRA, complete this Election Form and return
it to us. Under federal law, you have 60 days after the date of this notice to decide whether you want
to elect COBRA continuation coverage under the Plan.



Send completed Election Form to: _______________ [Instructions: insert name and address]



This Election Form must be completed and returned by mail by _______________ [Instructions:
insert date the form is due]. It must be post-marked no later than _______________ [Instructions:
insert date].



  (We) elect COBRA continuation coverage in the _______________ [Instructions: insert
IIf you do not submit a completed Election Form by the due date shown above, you will lose your
 right of Plan] (the continuation coverage. If
nameto elect COBRAPlan) as indicated below:you reject COBRA continuation coverage before the due
date, you may change your mind as long as you furnish a completed Election Form before the due date.
However, if you change your mind after first rejecting COBRA continuation coverage, your COBRA
                 Date of begin         date you furnish the completed Election Form. identifier)
continuation coverage willBirth on the Relationship to Employee
Name                                                                     SSN (or other

a. _________________________________________________________________________
Read the important information about your rights included in the pages after the Election Form.
       Coverage option elected: _______________ [Instructions: insert coverage option]




b. _________________________________________________________________________

       Coverage option elected: _______________ [Instructions: insert coverage option]




c. _________________________________________________________________________

       Coverage option elected: _______________ [Instructions: insert coverage option]
______________________________   ______________________________

Signature                        Date



______________________________   ______________________________

Print Name                       Relationship to individual(s) listed above



______________________________

______________________________

______________________________   ______________________________

Print Address                    Telephone number




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Description: A COBRA Election Form will allow an employee to continue its group health care coverage on a temporary basis under the former employer's plan, if the employee’s coverage would otherwise end due to termination or other change in employment status. This form also covers any dependants of the employee. This document can be customized to allow the employee’s unique information to be easily inserted into this form. This document should be used by employers seeking to establish continuation coverage under COBRA.