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November 2020

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2021 - Cobra Continuation Form

COBRA PARTICIPANTS

FOR USE FOR 2021 ENROLLMENT ONLY

To Be Completed By Employee:

First Name:

Last Name:

Middle Initial:

Address:

Apt. No:

City, State:

Zip Code:

County:

Sex:

Birthdate:

Marital Status:

Home Phone:

Cell Phone:

Email Address:

Spouse's Employer:

Other Insurance Coverage?

Policy Number:

Plan Number:

Insurance Plan:

Medicare Number:

Part A Effective:

Part B Effective:

LIST YOURSELF AND ALL ELIGIBLE DEPENDENTS

If you and your spouse are using different last names check applicable box:
Common Law Marriage
Wife Retaining Maiden

NAME: (Last, First Middle Initial):	Sex:	Date of Birth Month/Day/Year:	Social Security Number:	Relationship:
Self 1.
Spouse 2.
Name of Children:	Sex:	Date of Birth Month/Day/Year:	Social Security Number:	Relationship:
3.
4.
5.

HEALTH COVERAGE

An Employee must choose one of the available medical plans listed.

NEW ENROLLMENT

RE-ENROLLMENT

CHANGE INFORMATION

KAISER PERMANENTE-HMO (Option 1)
KAISER PERMANENTE - HIGH DEDUCTIBLE PLAN (Option 2)
I understand that as part of my membership, the health plan service agreement requires that any claim for money damages asserted by a member or the member’s heirs or personal representatives must be submitted to binding arbitration instead of court trial.

PREVIOUS ENROLLMENT: If you or any other member of your family has previously been a member of the Kaiser Foundation Health Plan of Colorado, please let us know so that we may locate any previous medical records and have them available for the Physician involved in your future medical care.

Were you a previous member? YES NO
If yes, your identification number:

ATU SELF FUNDED PPO PLAN (Option 3)

ATU SELF FUNDED PPO PLAN - HIGH DEDUCTIBLE (Option 4)
I certify that the information provided in this Application is true and complete to the best of my knowledge. I understand that any misrepresentation of information may void benefits retroactively to the date benefits began. I authorize use of all my (our) medical records for the Utilization Review, Quality Assurance and Peer Review programs conducted by the Plan or its agents.

I/We jointly certify that the above information is true and correct. I/We hereby authorize all doctors, hospitals, pharmacists or other institutions rendering care and treatment to furnish the RTD/ATU 1001 Health and Welfare Trust full information regarding treatment rendered (including copies of their records). I/We also authorize any Union Trust Fund Employer or Insurance Carrier to furnish the RTD/ATU 1001 Health and Welfare Trust information regarding benefits to which I/we may be entitled. A photo static copy of this authorization shall be considered as effective and valid as the original.

EMPLOYEE MUST SIGN AND DATE BELOW (to affirm any election made above):
I hereby declare that all the statements and answers to the above questions are true and I understand that they are the basis on which coverage may be extended under the Trust. I authorize the appropriate monthly payroll deductions for the year 2021 and subsequent years and understand that the payroll deduction may increase or decrease in subsequent years. I also understand that at the beginning of any calendar year I may waive coverage for that year.

Date:

Signature (type full name):