Tip for COBRA Election (employer/administrator-specific)

COBRA is expensive — you pay the full premium plus a 2% admin fee (typically 3-5x what you paid as an employee)

Tip for COBRA Election (employer/administrator-specific)

Compare ACA Marketplace plans at healthcare.gov — they may be cheaper, especially with subsidies

Tip for COBRA Election (employer/administrator-specific)

Losing employer coverage is a qualifying life event for ACA Marketplace enrollment (60-day window)

Insurancemoderate

COBRA Continuation Coverage Election

COBRA Election (employer/administrator-specific) · Employer / COBRA Administrator

Election to continue employer-sponsored health coverage after a qualifying event (job loss, reduction in hours, divorce, etc.). Must be elected within 60 days of qualifying event. Coverage retroactive to loss date.

Form Details

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Where to Submit This Form

📬

Mail to your former employer's plan administrator

The address is in the COBRA election notice you received.

Filing Deadline

60 days from the date of the COBRA election notice OR the date of the qualifying event, whichever is later.

Required Attachments

📎 Completed COBRA election form (provided by your former employer's plan administrator)
📎 First premium payment (you have 45 days after electing COBRA to make the first payment)

Processing Time

Coverage is retroactive to the date of the qualifying event once you elect and pay.

What Happens Next

Your coverage continues as if there was no gap. You have 45 days to make the first premium payment, which must cover all months back to the qualifying event.

Tips for This Form

✓ COBRA is expensive — you pay the full premium plus a 2% admin fee (typically 3-5x what you paid as an employee)
✓ Compare ACA Marketplace plans at healthcare.gov — they may be cheaper, especially with subsidies
✓ Losing employer coverage is a qualifying life event for ACA Marketplace enrollment (60-day window)
✓ COBRA lasts 18 months for most qualifying events (36 months for divorce or dependent aging out)

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Employer / COBRA Administrator or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.