Form 11-16. COBRA Coverage Election Form (Loss of Dependent Child Status)

In the case of the loss of dependent child status as a qualifying event, this election form can be provided to the employee or qualified beneficiary. It assumes that notifications from the employer, qualified beneficiary or covered employee occurred in the proper time frame and that the employer/plan administrator is, therefore, sending a Notice of COBRA Coverage Rights and election form to the affected qualified beneficiaries.

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