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COBRA Termination - Coverage Expiration

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					COBRA Termination -
Coverage Expiration
This notice politely and professionally informs an employee that their healthcare
coverage under COBRA is being terminated as of a specific date. COBRA coverage
allows an employee’s healthcare benefits to remain effective after termination of
employment for a certain amount of time. Customize the information of the parties, the
termination date of coverage, the commencement date of coverage, and more. This
notice is ideal for small businesses or other entities that want to courteously inform
employees of termination in COBRA coverage.
                ________________ [Instructions: Insert the Company’s name]
         _____________________ [Instructions: Insert the Plan Administrator’s name]
         ______________________ [Instructions: Insert the Company’s address line 1]
         ______________________ [Instructions: Insert the Company’s address line 2]

                                                       _________________ [Instructions: Insert the date]

_____________________ [Instructions: Insert the Employee’s name]
_____________________ [Instructions: Insert the Employee’s address line 1]
_____________________ [Instructions: Insert the Employee’s address line 2]

         Re:      Notice of Termination of COBRA Coverage

Dear ____________________, [Instruction: Insert the Employee’s name]

       This letter shall serve as formal notice that effective as of _______________________
[Instruction: Insert the termination date] (the “Termination Date”) you are no longer covered
by the Consolidated Omnibus Budget Reconciliation Act (“COBRA”) plan of
_______________________ [Instruction: Insert the Company’s name] (“Company”).

        In accordance with the requirements of COBRA, Company has been providing you with
continuation coverage under Company’s group health insurance plan since
________________________. [Instruction: Insert the date COBRA coverage started] Your
entitlement to coverage pursuant to COBRA terminates effective as of the Termination Date, and
all benefits will cease on that date.

        If you believe that your right to coverage under Company’s COBRA plan should remain
available, you can request that Company reconsider its determination by sending me a written
appeal. This appeal should including all information you wish to be reviewed, including without
limitation, your name, current address and the names of any covered dependents you wish to
include in your appeal. Should you have any questions or comments regarding the foregoing,
please do not hesitate to contact me.

                                                        Very truly yours,




                                                        _________________, [Instructions: Insert name]
                                                        COBRA Plan Administrator for ________________
                                                        [Instruction: Insert the Company’s name]




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Description: This notice politely and professionally informs an employee that their healthcare coverage under COBRA is being terminated as of a specific date. COBRA coverage allows an employee’s healthcare benefits to remain effective after termination of employment for a certain amount of time. Customize the information of the parties, the termination date of coverage, the commencement date of coverage, and more. This notice is ideal for small businesses or other entities that want to courteously inform employees of termination in COBRA coverage.