COBRA Election Form
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
document, also, covers the dependants of the employee. User’s
unique information can be easily inserted into this form.
ALL INFORMATION AND FORMS ARE PROVIDED “AS IS” WITHOUT ANY WARRANTY,
EXPRESS, IMPLIED, OR OTHERWISE, INCLUDING AS TO THEIR LEGAL EFFECT AND
COMPLETENESS. They are for guidance and should be modified to meet your needs and the
laws of your state. Use at your own risk. Docstoc and anyone who participated in providing or
modifying any form is not creating or entering into an Attorney-Client relationship. Docstoc
does not provide legal advice. The information and forms are not a substitute for the advice of
your own attorney.
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]
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______________________________ ______________________________
Signature Date
______________________________ ______________________________
Print Name Relationship to individual(s) listed above
______________________________
______________________________
______________________________ ______________________________
Print Address Telephone number
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