Sample COBRA Employer Notice of Event
Sample Employer Notice of Qualifying Event to Plan Administrator
Note: The following sample notice form may be used for employers to notify plan administrators of qualifying events. Before relying on this form, consult an attorney or benefits professional to make certain that the form fits your particular needs or factual circumstances.
NOTICE OF QUALIFYING EVENT
Employer information
Name: _________________
Address: _________________
Employee information
Name: _________________
Address: _________________
Home Phone: _________________
Work Phone: _________________
ID or SSN: _________________
Dept./Location: _________________
Plan #1: _________________
Plan #1 Id. No.: _________________
Type of coverage: _________________
Plan #2: _________________
Plan #2 Id. No.: _________________
Type of coverage: _________________
Covered spouse and/or dependent children information
Spouse name: _________________
Spouse SSN: _________________
Spouse address: _________________
Dependent child name: _________________
Dependent child SSN: _________________
Dependent child address: _________________
Dependent child name: _________________
Dependent child SSN: _________________
Dependent child address: _________________
Plan #1: _________________
Plan #1 Id. No.: _________________
Type of coverage: _________________
Plan #2: _________________
Plan #2 Id. No.: _________________
Type of coverage: _________________
Type of event
Employment termination
Reduction in employment hours
Divorce
Legal separation
Death of employee
Medicare entitlement
Loss of dependent status
Company bankruptcy
Miscellaneous information
Date of event: _________________
Date coverage ends: _________________
Date new dependent born or placed for adoption: _________________
Date employer notified: _________________
Other information: _________________
Possible extensions: _________________
Reprinted with permission. © CCH
Sample COBRA Employer Notice of Event: The following sample notice form may be used for employers to notify plan administrators of qualifying events.
Sample COBRA Employer Notice of Event
/resources/etools/sample_cobra_employer_notice_of_event.aspx
1065
none