COBRA

CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT
Department of Labor Group #: Foothill-De Anza CCD Contact: (866) 487-2365 or Human Resources at (650) 949-6225 Website: www.dol.gov COBRA General Information COBRA Rights Summary of COBRA Law HIPAA Information	FORMS
	SEE BELOW
REQUEST FOR CONTINUING HEALTH COVERAGE
COBRA Enrollment Forms COBRA Universal Enrollment Form* *You must complete the Universal Enrollment Form AND the appropriate form below to enroll into COBRA Forms and RATE INFORMATION** Full-time Employee: Form 1 - EPO Medical Plan Full-time Employee: Form 2 - PPO Medical Plan Full-time Employee: Form 3 - Kaiser Medical Plan Part-time Faculty: Form 4 - Kaiser Medical Plan PT Part-time Faculty: Form 5 - EPO Medical Plan PT Part-time Faculty: Form 6 - PPO Medical Plan PT **rates are subject to change.

Last Updated: Thursday, September 22, 2011 at 3:34:38 PM
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