COBRA Election Form by California Department of Human Resources
This file is the COBRA Election Form provided by the California Department of Human Resources. It includes sections for enrollee information, type of coverage, and completion and submission instructions. The form also contains a privacy notice regarding the information collected and its usage.
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How do I fill this out?
To fill out this form, start by providing your personal information and the necessary details for enrollment. Next, select the type of coverage you wish to enroll in and sign the document. Finally, ensure you follow the submission instructions carefully to complete the process.
How to fill out the COBRA Election Form by California Department of Human Resources?
1
Provide your personal information and the necessary details for enrollment.
2
Select the type of coverage you wish to enroll in.
3
Sign the document electronically.
4
Read the submission instructions carefully.
5
Submit the completed form by following the provided instructions.
Who needs the COBRA Election Form by California Department of Human Resources?
1
Employees who are losing their health benefits and need COBRA continuation coverage.
2
Employers providing COBRA information to employees.
3
HR departments handling employee benefits.
4
Former employees seeking continuation of health benefits.
5
Dependents of employees who need to continue their health benefits coverage.
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What are the instructions for submitting this form?
Submit the completed form to the address provided in the instructions section. If mailed, it must be postmarked by the specified date. CalHR Privacy Officer, 1515 S Street, North Building, Suite 500, Sacramento, California 95811-7258. For assistance, call 916-324-0455 or email CalHRPrivacy@CalHR.ca.gov. Ensure all required fields are filled out accurately before submission.
What are the important dates for this form in 2024 and 2025?
The COBRA Election Form must be completed and returned by the specified date. Ensure to check the form for exact dates for 2024 and 2025 submissions.
What is the purpose of this form?
The purpose of the COBRA Election Form is to allow employees and their dependents to continue their health benefits coverage after employment ends or other qualifying events. This form collects essential information required to process the continuation of coverage and ensures that the enrollee receives the necessary benefits. Properly completing and submitting this form is crucial for maintaining health benefits under the COBRA program.
Tell me about this form and its components and fields line-by-line.
- 1. Enrollee Information: Section to provide enrollee's name, address, social security number, and phone number.
- 2. Employee Information: If the enrollee is not the employee, the employee's name, social security number, and relationship to the employee must be provided.
- 3. Coverage Type: Checkboxes to select the type(s) of coverage to enroll in: medical, dental, vision.
- 4. Signature: Signature of the person electing COBRA coverage with the date.
- 5. Submission Instructions: Instructions on how to complete and return the form, including deadlines and the address for submission.
What happens if I fail to submit this form?
If you fail to submit this form, you may lose eligibility for COBRA continuation coverage.
- Loss of Coverage: Failing to submit the form by the deadline can result in the loss of health benefits coverage.
- Financial Impact: Without COBRA coverage, you may face significant out-of-pocket medical expenses.
- Administrative Delays: Late submission can cause delays in processing and interruption of benefits.
How do I know when to use this form?
- 1. Employment Termination: When an employee's job ends, and they need continued health coverage.
- 2. Reduction in Work Hours: When an employee's work hours are reduced, making them ineligible for the company's health plan.
- 3. Divorce or Legal Separation: When an employee's spouse needs to continue coverage due to divorce or legal separation.
- 4. Death of Employee: When dependents need to continue health coverage after the employee's death.
- 5. Dependent's Loss of Coverage: When a dependent child loses coverage due to aging out of parent's health plan.
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Can I save the changes I make to the COBRA Election Form?
Yes, after editing you can save and download the updated form.
What types of coverage can be selected in the form?
The form allows you to select medical, dental, and vision coverage options.
Where is the completed COBRA Election Form submitted?
Follow the provided submission instructions, which may include mailing, faxing, or emailing the form to the specified address.
Who can help with completing the required enrollment form?
The Personnel Office will assist in the completion of the required enrollment forms.
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