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How to Fill Out the New Cobra Form

The Consolidated Omnibus Budget Reconciliation Act of 1985, known as the COBRA, allows the continuation of health care coverage for employees and beneficiaries for a limited time when certain events result in a reduction in employee and beneficiary benefits. To qualify for COBRA benefits, you must belong to a health care plan qualifying for COBRA coverage, and experience a qualifying event that would cause you to lose health coverage. To recieve your benefits you must fill out the COBRA enrollment form, which shouldl be sent to you by your employer.

Things You'll Need

  • Cobra Enrollment Form
  • Pen
  • Photocopier or scanner
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Instructions

  1. Filling Out the COBRA Form

    • 1

      Type or print your or the enrollee's full name clearly in the order indicated on the form you are using.

    • 2

      Write or type in all vital information such as date of birth, social security number, gender, marital status, phone number, email address and current home address as directed.

    • 3

      List all eligible family members. Use their full legal names and social security numbers.

    • 4

      Check the appropriate boxes under the "Social Security Disability" and "Coverage under another Group Health Plan" headings.

    • 5

      Calculate your initial payment following the step-by-step instructions on the COBRA form provided you by your employer or insurance provider. Pay this amount within 45 days of your election to enroll in COBRA or you risk losing your COBRA coverage. If you don't plan to send in this payment with your enrollment form, make note of this amount and due date.

    • 6

      Sign and date the COBRA form. By signing the COBRA form you are agreeing to pay your monthly premium on time or lose coverage. You will also lose coverage if you become covered on another plan, the coverage period expires, the employer's plan is terminated, you or your spouse enroll in Medicare or a dependent reaches the plan's age limit.

    • 7

      Check over the enrollee section and fill in all information completely. Make sure everything is legible. Double-check your initial payment calculation.

    • 8

      Photocopy the completed form and put it in a safe place before you send it to your insurance provider so that you have a record for yourself. In a week, call or email to confirm it was received. If it was somehow lost in the mail, resend via fax, email or regular mail as directed by your insurance provider's representative.

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