Sample COBRA notice of rights to elect coverage

The following model notice may be used by plan administrators to notify qualified beneficiaries of their COBRA rights following a qualifying event under COBRA. This model form was issued by the Employee Benefits Security Administration (EBSA) as part of final regulations (69 FR 30083, May 26, 2004). Before relying on this form, consult an attorney or benefits professional to make certain that the form fits your particular needs or factual circumstances and reflects the latest guidance issued by the IRS.

Model COBRA Continuation Coverage Election Notice (Adobe PDF)
Model COBRA Election Notice.pdf