COBRA Continuation Coverage Election Form

Step 1 of 3 - General Information

  • General Information

  • If you did not meet the hours requirement for eligibility for the Benefit Period: May 1, 2021 through October 31 2021: your coverage can be extended through Subsidized COBRA being offered through the American Rescue Plan Act (“ARP”) at no cost for individuals who lost coverage due to a qualifying event that was a reduction in hours or involuntary termination of employment.

    In order to continue your coverage, you must fill out an Application and Election Form. Click “Next” to be taken to the Online Form.

    Important Facts

    To elect continuation coverage, complete this online Election Form. Under the American Rescue Plan Act, you have sixty (60) days after the date of this notice to decide whether you want to elect continuation coverage.

    • If you do not submit a completed Election Form by the June 30, 2021, you will lose your right to elect continuation coverage.
    • If you reject continuation coverage before the due date, you may change your mind as long as you furnish a completed Election Form before the due date.
    • However, if you change your mind after first rejecting continuation coverage, your continuation coverage will begin on the date you furnish the completed Election Form.