Forms and applications

COBRA Continuation of Coverage Application
For groups requesting effective dates prior to October 1, 2020. Use this form to apply for COBRA continuation of coverage.

Download* 

Continuation of Coverage Application (COBRA and Cal-COBRA)
For existing groups requesting effective dates of October 1, 2020, and later, this form replaces the "COBRA Continuation of Coverage Application”, the “Cal-COBRA Election”, and the “Continuing Group Coverage After Federal COBRA” forms. Use this form to apply for a continuation of coverage (federal COBRA or Cal-COBRA). 

Download 
(Fillable PDF)

Employer Notification of Qualifying Events under Cal-COBRA (ENF)
For effective dates prior to October 1, 2020. Complete this form when covered employees have an event that qualifies them for coverage under the California Continuation Benefits Replacement Act (Cal-COBRA, California Senate Bill 719).

Download

Employer Notification of Qualifying Events under Cal-COBRA
This form replaces the “Employer Notification of Qualifying Events under Cal-COBRA (ENF)” form for groups requesting changes effective October 1, 2020, and later. Complete this form each time a covered employee has a qualifying event that causes them to be eligible for continuation coverage under the California Continuation Benefits Replacement Act (Cal-COBRA). 

Download
(Fillable PDF)

Cal-COBRA Take-Over
New groups should use this form when changing carriers to Blue Shield for Cal-COBRA members covered under a previous carrier. Employers are responsible for notifying their Cal-COBRA members of the transition to a new carrier and Cal-COBRA members are required to fill out the form and submit to the Cal-COBRA team within 30 days of transition.

Download 

Continuing Group Coverage after Federal COBRA Cal-COBRA Election
For groups requesting effective dates prior to October 1, 2020. After exhausting 18 months of Federal COBRA benefits, a beneficiary may be eligible for an 18-month extension through Cal-COBRA. The beneficiary must contact Cal-COBRA (800) 228-9476 to request the extension and ensure they meet the requirements. If approved, the beneficiary will submit this form to formally accept the extension.

Download 

Cal-COBRA Election
Once the employer submits the ENF, an Election packet is sent to the beneficiary. The election form is completed by the beneficiary stating who is accepting coverage and plan choice. The election form should be submitted to Cal-COBRA for processing. NOTE: This form cannot be submitted without the employer first submitting the ENF.

Download 

Cal-COBRA Dental Election
For groups requesting effective dates prior to October 1, 2020. For dental-only groups: Once the employer submits the ENF, an Election packet is sent to the beneficiary. The election form is completed by the beneficiary stating who is accepting coverage and plan choice. The election form should be submitted to Cal-COBRA for processing. NOTE: This form cannot be submitted without the employer first submitting the ENF.

Download