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Northwest Carpenters Health and Security Plan
Forms Archive
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COBRA 2023
2023 COBRA Coverage Election Notice — Contains information of your COBRA Continuation Coverage rights.
2023 COBRA Application for 18-Month Qualifying Event (Washington) — Use this form if you are a participant losing dollar bank eligibility.
2023 COBRA Application for 18-Month Qualifying Event - (Oregon) — Use this form if you are a participant losing dollar bank eligibility.
2023 COBRA Application for 18-Month Qualifying Event - Kaiser (Oregon) — Use this form if you are a participant losing dollar bank eligibility.
2023 COBRA Application for 18-Month Qualifying Event (Eastern) — Use this form if you are a participant losing dollar bank eligibility.
2023 COBRA Application for 36-Month Qualifying Event - Retiree (Washington) — This form is for a dependent with a loss of eligibility.
2023 COBRA Application for 36-Month Qualifying Event (Washington) — This form is for a dependent spouse following a divorce, legal separation, death of a spouse, or a dependent child's loss of eligibility.
2023 COBRA Application for 36-Month Qualifying Event (Oregon) — This form is for a dependent following a divorce, legal separation, or death of a spouse, or a dependent child's loss of eligibility.
2023 COBRA Application for 36-Month Qualifying Event - Kaiser (Oregon) — This form is for a dependent following a divorce, legal separation, or death of a spouse, or a dependent child's loss of eligibility.
2023 COBRA Application for 36-Month Qualifying Event (Eastern) — This form is for a dependent following a divorce, legal separation, or death of a spouse, or a dependent child's loss of eligibility.
2023 COBRA Application for 11-Month Qualifying Event (Washington) — This form is for a participant or dependent with a disability.
2023 COBRA Application for 11-Month Qualifying Event (Oregon) — This form is for a participant or dependent with a disability.
2023 COBRA Application for 11-Month Qualifying Event (Eastern) — This form is for a participant or dependent with a disability.
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COBRA 2022
2022 COBRA Coverage Election Notice — Contains information of your COBRA Continuation Coverage rights.
2022 COBRA Application for 18-Month Qualifying Event (Western and Central Washington) — Use this form if you are a participant losing dollar bank eligibility.
2022 COBRA Application for 18-Month Qualifying Event (Eastern Washington, Idaho, Montana, Wyoming) — Use this form if you are a participant losing dollar bank eligibility.
2022 COBRA Application for 18-Month Qualifying Event - Northwest Carpenters Health and Security Plan (Oregon and SW W — Use this form if you are a participant losing dollar bank eligibility.
2022 COBRA Application for 18-Month Qualifying Event - Kaiser Permanente (Oregon and SW Washington) — Use this form if you are a participant losing dollar bank eligibility.
2022 COBRA Application for 36-Month Qualifying Event (Western and Central Washington) — This form is for a dependent spouse following a divorce, legal separation, death of a spouse, or a dependent child's loss of eligibility.
2022 COBRA Application for 36-Month Qualifying Event (Eastern Washington, Idaho, Montana, Wyoming) — This form is for a dependent following a divorce, legal separation, or death of a spouse, or a dependent child's loss of eligibility.
2022 COBRA Application for 36-Month Qualifying Event (Oregon and SW Washington) — This form is for a dependent following a divorce, legal separation, or death of a spouse, or a dependent child's loss of eligibility.
2022 COBRA Application for 36-Month Qualifying Event - Kaiser (Oregon and SW Washington) — This form is for a dependent following a divorce, legal separation, or death of a spouse, or a dependent child's loss of eligibility.
2022 COBRA Application for 36-Month Qualifying Event - Retiree (Western and Central Washington) — This form is for a dependent with a loss of eligibility.
2022 COBRA Application for 11-Month Qualifying Event (Western and Central Washington) — This form is for a participant or dependent with a disability.
2022 COBRA Application for 11-Month Qualifying Event (Eastern Washington, Idaho, Montana, Wyoming) — This form is for a participant or dependent with a disability.
2022 COBRA Application for 11-Month Qualifying Event (Oregon and SW Washington) — This form is for a participant or dependent with a disability.