Complete, sign and return this form to the COBRA Plan Administrator to elect COBRA coverage.

Step 1 of 4

  • MEMBER INFORMATION:

  • FIRST NAME
  • LAST NAME
  • LAST 4 DIGITS OF SOCIAL SECURITY NUMBER
  • If you are electing COBRA and you are not named above, enter your information below.

  • FIRST NAME
  • LAST NAME
  • RELATION TO MEMBER
  • Select Coverage type:

  • If you or any dependents were totally disabled at the time of loss of regular group coverage list names here:

  • Requirements for receiving COBRA under the American Rescue Plan Act of 2021 (ARP)

    The participant must initial that he or she understands each item below:
  • Have had an involuntary termination or reduction of hours of covered employment during the period beginning 11/1/2019, and ending 9/30/2021
  • I am not eligible for other group health coverage (or I was not eligible for other group health plan coverage during the period for which I am claiming premium assistance). I will notify the Funds immediately if group health coverage becomes available.
  • I am not eligible for Medicare (or was not eligible for Medicare during the period for which I am claiming premium assistance). I will notify the Funds immediately if Medicare health coverage becomes available.
  • I elected (or am electing) COBRA continuation coverage
  • By signing below, I confirm that I wish to enroll myself and (if applicable) the above-named dependents to a Subsidy COBRA continuation coverage health insurance policy with the Health Benefits Fund. I confirm that I have read and understand the COBRA continuation coverage letter that accompanied this election form concerning my rights and responsibilities under COBRA. I understand that I am obligated to immediately notify the Fund (or Employee Benefit Funds office) of any change of information that affects the health coverage eligibility of myself or any dependent(s). I understand that any person who knowingly files any claim or application for coverage and/or for health benefits which contains false information or conceals information may have his or her health coverage revoked and may be subject to legal action to recover the amount of related losses incurred by the Fund, including attorney's fees and court costs.
  • Date (month/day/year)
    Date Format: MM slash DD slash YYYY