COBRA Unavailability Notice


More Info
									COBRA Unavailability 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 Unavailability of COBRA Coverage


       This letter shall serve as formal notice that effective as of _________________
[Instructions: Insert the unavailability date] (the “Unavailability Date”) you are no longer
covered by the Consolidated Omnibus Budget Reconciliation Act (“COBRA”) plan of
___________________________. [Instructions: Insert the Company’s name] Your loss of
coverage is a result of _________________________________________________
[Instructions: Insert the event that caused COBRA loss] on __________________________.
[Instructions: Insert the date of the event] After reviewing the paperwork you have submitted,
the Company has determined that COBRA is not available to you and your covered dependents
as of the Unavailability Date because: _________________________________________.
[Instructions: Insert the reason(s) for unavailability of COBRA coverage] Company will not
make payments on any claims made on or after the Unavailability Date.

        If you believe that your right to coverage under the Company’s COBRA plan should
remain available, you can request that the 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]

© Copyright 2014 Docstoc Inc. registered document proprietary, copy not                      2

To top