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Continuing Group Coverage after Federal COBRA Cal-COBRA Election Form

Please return completed form to: Blue Shield of California Cal-COBRA, PO Box 629009, El Dorado Hills, CA 95762-9009.

If you have exhausted coverage under federal COBRA and were not entitled to the maximum period of 36 months or have been covered as

a domestic partner and the partnership terminated, you can apply to continue group coverage as allowed under the California Continuation

Benefits Replacement Act (Cal-COBRA) if you complete this election form.

I hereby elect Blue Shield of California subscriber coverage and/or family coverage for my eligible dependents listed below as may be contracted

for by the group contract holder. Blue Shield of California benefits, dues, and contract modifications will be in accordance with the group service

contract and as allowed under Cal-COBRA.

Employee information

Last name

First name

Blue Shield of California ID/SSN

Group/section number

Date of original event

COBRA original qualifying event or Cal-Cobra qualifying event if a domestic partner

Check one, enter required date

c Termination or reduction in covered employees hours (last day worked) ______/______/______

c Divorce or legal separation of the covered employee (qualifying event date) ______/______/______

c Entitlement to Medicare benefits by covered employee (qualifying event date) ______/______/______,

Covered employee name __________________________________________________, Blue Shield of California ID/SSN __________________

c Disqualification of dependent child under the plan (qualifying event date) ______/______/______

c Termination or reduction of hours due to disability (last day worked) ______/______/______

c Death of covered employee (qualifying event date) ______/______/______

c Termination of domestic partnership (qualifying event date) ______/______/______

Qualifying elector information

Last name

First name

Blue Shield of California

ID/SSN

Address

Phone number

(street, city, state, ZIP)

(

)

Date of birth

Gender

Married?

Domestic partnership?

(month, day, year)

c Male c Female

c Yes

c No

c Yes

c No

Does qualifying elector have other health coverage?

Does qualifying elector have Medicare?

Does qualifying elector have Medicare due to disability?

c Yes

c No

c Yes

c No

c Yes

c No

If HMO, please indicate your Personal Physician

Phone number

Name

(

)

Signature of elector

X ______________________________________________________________________________________ Date __________________

Please print signature name

X ____________________________________________________________________________________________________________

(see reverse)

Continuing Group Coverage After Federal Cobra Cal-Cobra Election Form - Blue Shield Of California

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