• 401. General Information
• 402. Qualified Beneficiary
• 403. Initial General COBRA Notice
• 404. COBRA Qualifying Events
• 405. Retiree Benefit Plan Alternate Coverage
• 406. Leaves of Absence
• 407. Loss of Group Coverage in Anticipation of a Qualifying Event
• 408. COBRA Election Notice and Election Form
• 409. COBRA Qualifying Event Notification Responsibilities
• 410. Notice of Unavailability of Continuation Coverage
• 411. Election Period
• 412. Length of COBRA Coverage
• 413. COBRA Premiums
• 414. Gross Misconduct
• 415. Noncompliance Penalties and Fines
• 416. Open Enrollment Period
• 417. COBRA in Retirement
• 418. Loss of COBRA Continuation Coverage
• 419. Completion of COBRA Enrollment Forms
• 420. Dental/Vision COBRA Premiums
• 421. Insurance Plan Addresses

• View all Section 400

  Attachments

• Attachment A - Initial General COBRA Notice
• Attachment B - COBRA Election Notice
• Attachment C - COBRA Continuation Election Form
• Attachment D - Notice of Unavailability of Continuation Coverage
• Attachment E - Initial COBRA Notice Log
• Attachment F - COBRA Election Notice Log
• Attachment G - Monthly COBRA Status Report
• Attachment H - COBRA Calendar

• Table of Contents

   

419. Completion of COBRA Enrollment Forms

Delta Dental Plans - Delta Premier and Delta Preferred Provider Option (PPO)

Wolfpack Insurance Services, Inc., a company that provides administrative COBRA services, handles COBRA enrollments for Delta Dental (Delta). The Dental Plan Enrollment Authorization (STD. 692) will serve as the COBRA Continuation Enrollment Form for all COBRA enrollments in the Delta Premier and Delta Preferred Provider Option (PPO) plans. Instructions are provided below. The Personnel Office should contact the eligible employee, spouse, or domestic partner to obtain the information necessary to complete the form.

Note: Dependents of rank and file employees have a lower level of coverage under the Delta Premier - Basic Plan and pay a lower COBRA premium for dependent only coverage. The Personnel Office should reflect the dependent only COBRA premium when completing the STD. 692.

PrePaid Dental Plans - DeltaCare USA and SafeGuard

The Dental Plan Enrollment Authorization (STD. 692) will serve as the COBRA Continuation Enrollment Form for all COBRA enrollments in the DeltaCare USA and SafeGuard plans. Instructions are provided below. The Personnel Office should contact the eligible employee, spouse, or domestic partner, to obtain the information necessary to complete the form.

Bargaining Unit 5

For employees in Bargaining Unit 5, COBRA enrollment forms for dental coverage should be sent to the California Association of Highway Patrolmen (CAHP) Dental Trust. Contact CAHP for COBRA dental premiums information. Unit 5 employees have vision coverage through the State-sponsored Vision Service Plan (VSP) and COBRA enrollments for their vision coverage should be sent to VSP.

Bargaining Unit 6

For employees in Bargaining Unit 6, COBRA enrollment forms should be sent to the California Correctional Peace Officers Association (CCPOA) Benefit Trust. Personnel Offices should assist employees, spouses, domestic partners, and dependent children with the completion of the COBRA enrollment forms and submit forms to CCPOA. Contact CCPOA for COBRA dental and vision premiums information.

Telephone numbers and mailing addresses are listed in Section 421. Do not send the COBRA enrollment forms or premium payments to DPA, SCO, or CalPERS.

Instructions for completion of the STD. 692:

1. Check COBRA Box.

2. Section A: Enter the name and social security number of the eligible enrollee. Mark NEW in Section A-1.

3. Section B: Enter name of dental plan (e.g., Delta Premier-Enhanced, Delta Premier-Basic, Delta Premier-Basic - Dependent Only, Delta Preferred Provider Option (PPO), PMI, SafeGuard-Standard, or SafeGuard-Enhanced). For Bargaining Units 5 and 6 employees, reflect the appropriate dental plan name.

4. Enrollee's signature/date required in Section D.

5. Section E:

   E-9   Enter the total monthly premium to be paid by the eligible enrollee.

   E-12   Enter the date of the qualifying event (e.g. divorce, termination of domestic partnership, termination from employment, child ceases to be a dependent).

   E-14   Enter effective date of action (the first day of the month after loss of coverage).

   E-17   Enter State employee's agency name.

   E-18   Enter the qualifying event (e.g. divorce, termination of domestic partnership, termination from employment, child ceases to be a dependent). If the enrollee is not the employee, then enter the name and social security number of the employee. Provide a telephone number if available.

   E-19   Signature of authorized agency representative.

   E-20   Telephone number of authorized agency representative.

   E-21   Enter date completed.

6. If the employee elects coverage and enrolls his/her family members at the same time, then only one form listing all family members is needed. Retain the agency copy (pink copy) of the completed STD. 692 in the employee's personnel file and send the original (white copy) and plan copy (yellow copy) to the plan or its designee. The green copy of the STD. 692 should be sent to the enrollee. Do not send a copy to DPA, SCO, or CalPERS.