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

Existing COBRA Member Data Sheet

Click here for a printable form

Name of Employer :
Name of COBRA Participant :
Address :
City, State, Zip :
Date of Birth :
Social Security Number :
Telephone Number :
Medical Plan Enrolled In:
Premium for Medical :		Coverage Type (i.e. single) :
Dental Plan Enrolled In:
Premium for Dental :		Coverage Type (i.e. single) :
Other Coverage Enrolled In:
Premium for Other Coverage :		Coverage Type (i.e. single) :
Dependent Name	Date of Birth


Date COBRA Began :
Date COBRA Paid Through :
What event activated eligibility?	Termination of Employment (Voluntary) Termination of Employment (Involuntary) Retirement Reduction in Hours Termination due to Total Disability Medicare Eligibility Divorce or Legal Separation Child's Loss of Dependent Status Death of Employee
Are premiums to be returned to the employer? If yes, please indicate address to remit premiums
Address :
City, State, Zip :

*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.