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COBRA Termination Notice

VIEWS: 10 PAGES: 3

This letter courteously informs an employee that they will no longer be covered under COBRA as of a certain date. In addition, the employee’s dependents will no longer be covered under the act as either. Customize the information of the parties, the reason for termination of COBRA coverage, the date of termination, and more. This letter is ideal for small businesses or other entities that want to politely inform employees that they are no longer covered under COBRA.

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									COBRA Termination Notice
This letter courteously informs an employee that they will no longer be covered under
COBRA as of a certain date. In addition, the employee’s dependents will no longer be
covered under the act as either. Customize the information of the parties, the reason for
termination of COBRA coverage, the date of termination, and more. This letter is ideal
for small businesses or other entities that want to politely inform employees that they
are no longer covered under COBRA.
                ________________ [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]

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

         Re:      Notice of Termination of COBRA Coverage

Dear ___________________, [Instructions: Insert the Employee’s name]

        This letter shall serve as formal notice that effective as of _____________________
[Instructions: 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”). Coverage
under Company’s COBRA plan will cease on the Termination Date because
_____________________________________________________________________________.
[Instructions: Insert the reason(s) for termination of coverage] 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 _______________
                                                        [Instructions: Insert the Company’s name]




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