CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (C.O.B.R.A.)

Forms

• Universal Enrollment Form

*You must complete the Universal Enrollment Form AND the appropriate CalPERS form(s) below.

• Foothill - De Anza Request for Continuing Health Coverage  (EAP/Dental/Vision only)
• CalPERS C.O.B.R.A. Election Form for Actives - Form PERS HBD-85  (For CalPERS and medical only, Active only)
• CalPERS C.O.B.R.A. Election Form for Retirees - Form PERS HBD-85R  (For CalPERS and medical only, Retirees/Survivors)

Additional Information:

• C.O.B.R.A. General Information
• C.O.B.R.A. Rights
• Summary of C.O.B.R.A. Law
• 2024 C.O.B.R.A. Contribution Rates