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: