Adams® COBRA Election Form for Employee, 1-Use Interactive Digital Legal Form

1 form

This universal form allows employees to elect continuation of their employer’s group health coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA), for themselves, their spouse, former spouse or dependent children due to a qualifying event.

Available in increments of 1
  • Form formally requests continuation of health coverage under COBRA for covered employee, spouse, former spouse or dependent children
  • Qualifying events include resignation, termination not due to misconduct, reduction in hours, or a child’s loss of coverage due to dependent status
  • Spouse or former spouse may submit for themselves and minor children in situations of divorce, legal separation, or death of a covered employee
  • Attorney-reviewed form valid for general use in every state
  • Click the secure link in your account to begin the interactive Q&A that creates your legal form
  • Responses auto save as you work; return any time to complete your secure form at
  • Online Guidance Notes offer additional information on signing, filing, and executing your documents
  • Download to save and print your customized PDF file
More Information
Item # DLF498-SL
Purchasing Quantity 1 form
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