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For Further Assistance, you may contact the Department of Labor’s Employee Benefits
Administration at 1-866-444-3272, or online at https://www.askebsa.dol.gov/WebIntake.
DEPENDENT INFORMATION (Parent or guardian should sign for minor children.)
Name
Date of Birth
Relationship to Employee
SSN (or other identifier)
. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage.
2. I am NOT eligible for other group health plan coverage.
3. I am NOT eligible for Medicare.
4. The qualifying event was an involuntary termination or a reduction in hours.
I make an election to exercise my right to ARPA premium assistance. To the best of my knowledge and belief all of the answers I have
provided on this form are true and correct.
Signature __________________________________________________ Date ____________________________
Type or print name __________________________________________ Relationship to employee _________________________
. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage.
2. I am NOT eligible for other group health plan coverage.
3. I am NOT eligible for Medicare.
4. The qualifying event was an involuntary termination or a reduction in hours.
I make an election to exercise my right to ARPA premium assistance. To the best of my knowledge and belief all of the answers I have
provided on this form are true and correct.
Signature __________________________________________________ Date ____________________________
Type or print name __________________________________________ Relationship to employee _________________________
. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage.
2. I am NOT eligible for other group health plan coverage.
3. I am NOT eligible for Medicare.
4. The qualifying event was an involuntary termination or a reduction in hours.
I make an election to exercise my right to the ARPA premium assistance. To the best of my knowledge and belief all of the answers I
have provided on this form are true and correct.
Signature __________________________________________________ Date ____________________________
Type or print name __________________________________________ Relationship to employee ______________________
Name
Date of Birth
Relationship to Employee
SSN (or other identifier)
Name
Date of Birth
Relationship to Employee
SSN (or other identifier)
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