COBRA Applications

Tags COBRA cobra

COBRA Applications

Employees and/or their dependents who qualify for COBRA (Consolidated Omnibus Budget Reconciliation Act) are notified via mail with an information packet, including a COBRA Election form. To continue coverage for medical, dental and/or vision insurance through COBRA, please complete and print the corresponding application. Please return the completed application and Election Form to Human Resources. 


Qualifying events including, but not limited to, the following determine COBRA eligibility:

End of employment
Reduction in hours of employment
Entitlement to Medicare
Divorce or legal separation
Loss of dependent child status
Termination of coverage due to change in spouse’s employment
Death of employee


Article ID: 98869
Thu 2/20/20 1:46 PM
Thu 2/27/20 10:19 AM