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COBRA Forms

General Instructions:

  • Each form here contains a brief description to help you determine which one(s) you may need to use.
  • Please read each form carefully as additional instructions may apply.
  • Most of our forms are available in multiple formats - please choose which format works best for you.
  • Many of our PDF forms allow electronic signatures. For information on how to sign a PDF form electronically, click here.
  • Please note that if you send us information, such as a completed form, through unsecured email (for example, Gmail, Yahoo Mail, Hotmail, etc.), we cannot guarantee that your protected health information (PHI) is secure. Depending on what you need to send us, we provide other secure methods of submission, such as our member portal and DocuSign. Please choose the submission method that you are most comfortable with.

COBRA Forms:

  • COBRA Election Form Complete Online
    ​Use this form to indicate which COBRA coverage election(s) you want and for whom you want coverage. Please use this form only if you're eligible for COBRA and only if you've received a COBRA Election Notice in the mail. Note: The election(s) you make must match the available option(s) we provided to you in your COBRA Election Notice (usually listed on pages 6 and 7, but please check your specific notice, as these page numbers may differ). If your election(s) don't match, then your COBRA election request may be delayed.
  • COBRA Notice of Disability Form Download pdf
    Use this form when you're already on COBRA and want to extend your COBRA coverage due to a qualifying disability. To qualify for this extension, the Social Security Administration (SSA) must have sent you a determination letter ("Notice of Award") indicating that a qualified beneficiary became disabled within the first 60 calendar days following the qualifying event of a termination of employment or a reduction of hours of the employee covered under the Plan. You must also include a copy of this Notice of Award letter with your submission. Here is an example of this letter.​​​
  • COBRA Notice of Qualifying Event Form Download pdf
    Please submit this form to your employer. Use this form when any of the following qualifying events occur and, due to the qualifying event, you're requesting COBRA coverage:

1) A spouse covered under the Plan becomes divorced or legally separated from the covered employee

2) The covered employee reduced or eliminated his or her spouse’s Plan coverage in anticipation of their divorce or legal separation, and the anticipated divorce or legal separation has subsequently occurred

3) A child covered under the Plan ceases to be a dependent under the terms of the Plan.

  • COBRA Notice of Second Qualifying Event Form Download pdf
    Use this form when any of the following second qualifying events occur and, due to the qualifying event, you're requesting an extension of COBRA coverage:

1) A spouse who is receiving COBRA coverage becomes divorced or legally separated from the covered employee

2) A child covered under the Plan ceases to be a dependent under the terms of the Plan

3) The covered employee dies while one or more qualified beneficiaries are receiving COBRA coverage.

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Access other Member Forms here.