Forms Available For Download

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COBRA Administration

• EXHIBIT 1 - COBRA Model Notice (non-ARRA) - English Version
• EXHIBIT 1a - COBRA Model Notice (non-ARRA) - Spanish Version
• EXHIBIT 2 - COBRA Model Election Notice (non-ARRA) - English Version
• EXHIBIT 2A - COBRA Model Election Notice (non-ARRA) - Spanish Version
• EXHIBIT 3 - COBRA Model Supplemental Information Notice - Plans that are subject to continuation coverage provisions under Federal or State law should provide the Supplemental Information Notice to all individuals who elected and maintained continuation coverage based on the following qualifying events:
  • all qualifying events related to a termination of employment that occurred from 3/1/10 through 4/14/10 for which notice of the availability of the premium reduction available under ARRA was not given; or
  • reductions of hours that occurred during the period from 9/1/08 through 5/31/10 which were followed by a termination of the employee's employment that occurred on or after 3/2/10 and by 5/31/10
• EXHIBIT 4 - COBRA Model Notice of Extended Election Period - Plans that are subject to continuation coverage provision under Federal or State law must provide before the end of the required time period for providing a COBRA election notice, the Notice of Extended Election Period to all individuals who:
  • experienced a qualifying event that was a termination of employment at some time from 4/1/10 through 4/14/10;
  • were provided notice that did not inform them of their rights under ARRA, as amended by CEA; and
  • either chose not to elect COBRA continuation coverage at that time or elected COBRA but subsequently discontinued that coverage
• EXHIBIT 5 - COBRA Model Updated Alternative Notice - Insurance issuers that offer group health insurance coverage that is subject to comparable continuation coverage requirements imposed by State law must provide the Alternative Notice to all qualified beneficiaries, not just covered employees, who have experienced a qualifying event through 5/31/10.
• EXHIBIT 6 - COBRA Premium Reduction Fact Sheet - English Version
• EXHIBIT 6 - COBRA Premium Reduction Fact Sheet - Spanish Version

Eligibility / Enrollment

• Enrollment/Change Form
• Flexible Spending Account Enrollment Form
• Healthy Partners - Under 50 Lives
• Healthy Partners - Over 50 Lives
  

Health Care Claim Forms

• Dental Claim Form
• Flexibility Spending Account Withdrawal Request
• HRA Debit Card Claim Form
• Medical Claim Form
• Medical Claim CIGNA Form
  
• PHF Claim Form
• RESTAT Prescription Drug Manual Claim Form
• Transportation Reimbursement Account Claim Form
• Vision Care Claim Form

Protect Health Information (PHI) Release Information

• PHI Release Form