COBRA
COBRA allows for continuation of coverage for a maximum of 18 months upon separation from employment. HMO participants are eligible for an additional six months, for a maximum of 24 months. If you choose COBRA continuation coverage, you’ll pay the full cost of your premium(s) directly to ERS. Coverage is limited to the benefits you have when you leave employment.
This form acknowledges that employees have read and understood the information regarding the continuation of health coverage.
Additional information can be found on the ACC Benefits website.
Download the form and complete electronically.
Note: When you first click on the link to download the form, you will be in document preview mode, and cannot enter data into the form. Click the download icon in your browser in order to edit, save, or print the form in Adobe Acrobat.
If you are unable to access the form or receive an error message, send a screenshot of your entire screen and the message to hrbenefits@austincc.edu. Assistance will provided as soon as possible.
Bring your completed form to new employee orientation (NEO) and provide it to the Benefits Administrator. If you do not have access to a printer, a blank form will be available at NEO.
Use this form to enroll eligible dependents, Social Security Numbers are required.
"COBRA" Form
COBRA-Continuation Notification Form.pdf