COBRA Care

Expanding options. Controlling costs.

How it Works

	What is COBRA?
	What is HIPAA?
	Services Provided
	COBRA Administration Quote Request
	COBRA Administration Proposal
	Employer Sign Up
	How do I Enroll a Member in COBRA?
	Qualifying Event Notice
	Qualifying Event Notice (printable)
	Existing COBRA Member Data Sheet
	Special COBRA Enrollment Rights Notice/Waiver
	Contact Us
	Click Here for More Information
	Choice Care Card Home Page

Choice COBRA* Provides All COBRA and HIPAA Services to Keep Our Clients in Compliance

Employer Sign-Up

Click here for a printable version

Company Legal Name :
Company Address :
City, State, Zip :
Contact Person :
Phone :
Fax :
Email address of contact :
Total Number of Eligible Employees :
(Please note there is a monthly minumum charge of $30)
Medical Carriers - click on the link to view/change the plan information

Dental Carriers - click on the link to view/change the plan information

Vision Carriers - click on the link to view/change the plan information


HRA	Plan Year :
	Vendor :
Amount Funded by Employer
Single
EE & Spouse
EE & Child(ren)
Family

FSA	Plan Year :
	Vendor :

Waiting Period for new hires :
Medical Dependent Age Maximum :			Full-Time student Age Maximum :
Dental Dependent Age Maximum :			Full-Time student Age Maximum :
Vision Dependent Age Maximum :			Full-Time student Age Maximum :
Ineligible dependents covered until :		End of Month End of Year

*COBRA and HIPAA administration is provided by COBRA Administration and Health Services, Inc. (CAHS) under the Choice COBRA brand name. The service contract for these services is between the employer and CAHS.