Sample Checklist for COBRA Recordkeeping

INDIVIDUAL'S COBRA RECORD

1. Date initial COBRA notice sent [when employee becomes covered under plan] ______________

2. Date employee and spouse confirmed receipt of initial notice ______________

Qualifying Event Other than Divorce or Loss of Dependent Status

3. Date qualifying event occurred ______________

4. Date 30 days after date in (3) [deadline for employer to notify administrator] ______________

5. Date on which administrator notified ______________

6. Date 14 days after date in (5) [when administrator must notify qualified beneficiary] ______________

7. Date coverage is lost under plan by reason of qualifying event ______________

8. Date qualified beneficiary notified of election rights ______________

9. Date 60 days after later of date in (7) or (8) [deadline for making election] ______________

10.Date on which qualified beneficiary makes COBRA election ______________

Divorce or Loss of Dependent Status Qualifying Event 

11. Date of divorce or loss of dependent status ______________

12. Date coverage is lost under plan by reason of qualifying event ______________

13. Date 60 days after later of date in (11) or (12) [deadline for employee or qualified beneficiary to notify administrator] ______________

14. Date employee or qualified beneficiary notified administrator of qualifying event.______________

15. Date 14 days after date in (14) [when administrator must notify qualified beneficiary] ______________

16. Date administrator notified qualified beneficiary of election rights  ______________

17. Date 60 days after later of date in (15) or (16) [deadline for making election] ______________

18. Date on which qualified beneficiary makes election ______________

   Waiver and Revocation of COBRA Rights     

19. Date of waiver of COBRA rights  ______________

20. Date in (9) or (17), whichever is applicable [deadline for making election] ______________

21. Date of revocation of waiver

Payment of COBRA Premiums

22. Date 45 days after date in (10) or (18), whichever is applicable --initial premium due date [payment is due for each month for which the 30-day grace period has expired]  ______________

23. Date payment of initial premium made ______________

24. For each remaining month --due date, end of grace period, actual payment date:   

 End of 30-Day

    Month        Due Date        Grace Period        Payment Date       

   _______________________________________________________________

   _______________________________________________________________

   _______________________________________________________________

   _______________________________________________________________

 25.Premium not paid timely, coverage terminated  ______________

Changes in Premiums, Status, Coverage, etc.   

26.Change in COBRA premium --New     

  Determination Period: 

• Notification of change made ______________
• Effective date of change ______________
• New premium determined ______________

27.Disability determination  

• Date of determination  ______________
• 60 days after date in 27(a) ______________
• Date of notification. ______________
• Month COBRA rate changes to 150% . ______________

28. Date of secondary qualifying event ______________

29. Change of coverage:

• Effective date of change ______________
• New premium determined.______________

30. Medicare entitlement:

• a. Effective date of employee's entitlement ______________
• b. Employee's coverage terminated ______________
• c. Extension of coverage for other beneficiaries ______________
• d. Effective date of other beneficiaries' coverage ______________

31. Date of coverage under another health plan [coverage may be terminated only if other coverage has no exclusion with respect to preexisting condition]______________

Sample Checklist for COBRA Recordkeeping. 1. Date initial COBRA notice sent