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Summary of the COBRA Premium Form


Summary of the COBRA Premium Form

 
Summary of the COBRA Premium Form
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The Summary of the COBRA Premium Form provides information to employees and former employees about their rights to participate in the COBRA program. This form contains important information about who may be eligible to participate in COBRA and what is required of those individuals in order to ensure that they maintain coverage and meet all coverage requirements, including information about how the former employees may pay for their premiums.

 

More Information about COBRA

 

The 1986 Consolidated Omnibus Budget Reconciliation Act (COBRA) extends group health care coverage for employees and other beneficiaries that have involuntarily lost their employment or had a reduction in the number of hours that they work. COBRA allows qualifying individuals to continue to receive group health care coverage at a group rate for a limited period of time.

 

Traditionally, employees were required to complete the COBRA Continuation Coverage Election form within 60 days of a qualifying incident in order to qualify for COBRA coverage. However, the 2009 Stimulus Plan extended COBRA rights for qualifying employees.* (Continuing reading to learn more about these changes.)

 

Who Qualifies for COBRA Continuation

Employees that have involuntarily lost their jobs or had a reduction in their hours may elect to be covered by COBRA. In order to be covered, employees need to complete the COBRA Continuation of Coverage form within 60 days of a qualifying event, such as a lay off.

 

Potential COBRA beneficiaries include:
  • Former employees
  • Retirees
  • Spouses of former employees or retirees
  • Former spouses of former employees and retirees
  • Former spouses of employees and retirees
  • Dependent children  

Employers should provide employees with this form in order to ensure that they communicate their employees’ and former employees’ rights to them in a suitable manner. There have been many changes to the COBRA program in 2009, so employers not only need to be familiar with those changes, but they need to be sure to communicate those changes with their employees by providing their employees with all necessary forms and documentation.  

Product Specifications:

  • This for is 8.5" x 11"
  • 50 sheets/pkg

 
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