Provide this form to an employee or employee's spouse within 90 days of the commencement of Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage or the first date at which the plan administrator is required to advise a qualified beneficiary of the right to elect coverage. Depending on your company’s plan, different options will apply.
This form is free for CalChamber members. Login and access the form now at
HRCalifornia.com. Not a member?
Find out more about the many benefits of membership.