COBRA Continuation Coverage Election Form
Participant Information
Full Name
Social Security Number
Mailing Address
City
State
ZIP Code
Phone Number
Email Address
Coverage Information
Qualifying Event
Date of Qualifying Event
Plan Names/Types
COBRA Coverage Begin Date
Election
I elect to continue coverage under COBRA
Covered Individuals (If family coverage, list names, SSNs, and relationship)
Signature
Signature
Date