COBRA and CAL-COBRA

Form		Download
COBRA Employee Application		Download*
Employer Notification of Qualifying Events under Cal-COBRA (ENF) 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
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 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 After exhausting 18 months of Federal COBRA benefits, a beneficiary may be eligible to an 18-month extension through Cal-COBRA. 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 employer first submitting the ENF.		Download
Cal-COBRA Dental Election 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 employer first submitting the ENF.		Download