Sample COBRA employee notice of event
Note: The following sample notice form may be used for employees to notify employers of qualifying events or other changes in status that affect benefit coverage. 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 TO EMPLOYER OF QUALIFYING EVENT
Employer information
Name:
Address:
Covered employee information
Name:
Address:
Home Phone:
Work Phone:
ID or SSN:
Covered qualified beneficiary (spouse and/or dependents) information
Name:
Address:
Home Phone:
Relationship to Employee:
New born child or adopted child information
Name:
Address:
Date born to or placed for adoption with employee:
Divorce (attach documentation of divorce). Date of event:
Legal separation (attach documentation). Date of event:
Loss of dependent status. Date of event:
Social Security Disability (attach SSA determination letter which needs to be submitted within 60 days from the date of the determination).
Plan(s) information
Plan Name:
Plan ID No.:
Type of coverage:
Return completed form to
Plan administrator name:
Address:
<p>Note: The following sample notice form may be used for employees to notify employers of qualifying events or other changes in status that affect benefit coverag</p>
Sample COBRA employee notice of event
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