COBRA Eligibility Form


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									This form includes the necessary information that an employer must give to its former
employee when that employee seeks to establish continuation coverage under COBRA.
This document allows an employer to collect crucial information from the employee to
ensure that the employer remains compliant with the COBRA requirements. This
COBRA Eligibility Form should be used by every employer that is extending COBRA
benefits. This form allows for customization to fit the needs of the employer and
includes opportunities to include optional language, such as for additional benefits.
                                   COBRA Eligibility Form

________________ [Instructions: insert date]

Dear ________________ [Instructions: insert name of recipient]

This notice contains important information about your right to continue your health care
coverage in the ________________ [Instructions: insert name of group medical plan]
(“Plan”). You should read this notice very carefully.

In order to elect to continue COBRA coverage, you must follow the instructions on the next page
to complete the enclosed Election Form and submit it to us. If you do not elect COBRA
continuation coverage, your coverage under the Plan will end on ________________
[Instructions: insert date] due to: [Comment: check the appropriate box]

        Divorce or legal separation                End of employment

        Reduction in hours of employment           Death of employee

        Loss of dependent child status             Entitlement to Medicare

Each person (“eligible beneficiary”) in the categories checked below is entitled to elect COBRA
continuation coverage, which will continue group health care coverage under the Plan for up to
________________ [Instructions: amount of time. 18 or 36] months:

        Spouse or former spouse
        Employee or former employee
        Dependent child(ren) covered under the Plan on the day before the event that caused
           the loss of coverage
        Child who is losing coverage under the Plan because he or she is no
          longer a dependent under the Plan

If elected, COBRA continuation coverage will begin on ________________ [Instructions: date]
and can last until ________________ [Instructions: date].
You may elect any of the following options for COBRA continuation coverage:

________________ [Instructions: insert any additional options, if applicable]

COBRA continuation coverage will cost ________________ [Instructions: insert amount] per
month. You do not have to send any payment with the Election Form. Important additional
information about payment for COBRA continuation coverage is included in the pages following
the Election Form.

You should contact ________________________________ [Instructions: insert name of
person administering the Plan. Also, include address], if you have any questions about this
notice or your rights to COBRA continuation coverage,


________________ [Instructions: insert name]

© Copyright 2012 Docstoc Inc.                                                                 3

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