DPA - Benefits - Benefits Administration Manual - Section 400: Consolidated Omnibus Budget Reconciliation Act (COBRA)

	Department of Personnel Administration
	Benefits Administration Manual
	Section 400 401. 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 Navigation Table of Contents	Consolidated Omnibus Budget Reconciliation Act (COBRA) 421. Insurance Plan Addresses Send Enrollment forms and premium payments to the following addresses: Delta Dental Plans For Delta Premier and Delta Preferred Provider (PPO) enrollees, send the STD. 692 and premium payments to: Wolfpack Insurance Services, Inc. P.O. Box 833 Belmont, CA 94002-0833 Attn: COBRA – State of California 1-800-296-0192 Pre-Paid Dental Plans DeltaCare USA 12898 Towne Center Drive Cerritos, CA 90703 Attn: COBRA UNIT 1-800-422-4234 SafeGuard P.O. Box 30910 Laguna Hills, CA 92654-0910 Attn: COBRA UNIT Billing and Eligibility 1-800-880-1800 Union Trust Dental Plans Unit 6 CCPOA Benefit Trust 2515 Venture Oaks Way, Suite 200 Sacramento, CA 95833-4233 1-800-468-6486 Unit 5 (Dental enrollments only) CAHP Dental Trust 2030 V Street Sacramento, CA 95818 1-800-734-2247 Vision Plan VSP Attn: COBRA UNIT – Mailstop 229 P.O. Box 997100 Sacramento, CA 95899-7100 You may also fax the STD. 700 to VSP at fax number (916) 463-9031 1-800-852-7600 Ext.4636 Back to Top