You can open the Cobra Election Notice Template in multiple formats, including PDF, Word, and Google Docs.
Cobra Election Notice Template Printable | Editable FormSample
Examples
[Name of the Employee]
[Employee’s ID]
[Employee’s Address]
[Employee’s Phone]
[Employee’s Email]
[Name of the Employer/Plan Administrator]
[Employer’s ID]
[Employer’s Address]
COBRA Continuation Coverage Election Notice
This notice informs you of your rights under the Consolidated Omnibus Budget Reconciliation Act (COBRA) to continue your health insurance coverage after your employment has ended, or when other qualifying events occur.
You may be eligible for COBRA continuation coverage if you experience any of the following events:
1. Termination of employment (except for gross misconduct)
2. Reduction in hours of employment
3. Death of the covered employee
4. Divorce or legal separation from the covered employee
5. The covered employee becomes entitled to Medicare.
COBRA coverage lasts for a maximum of 18 months after the qualifying event, with certain conditions allowing for an extension of coverage up to 36 months for other qualifying events.
You must elect COBRA coverage within 60 days from the date of this notice or from the date of a qualifying event, whichever is later.
The employee is responsible for paying the entire premium for COBRA coverage, plus a 2% administrative fee. The premium must be paid within 30 days of your election.
To elect COBRA continuation coverage, please complete the attached election form and return it to [Employer/Plan Administrator’s Address] by [Deadline Date].
If you have questions concerning your COBRA rights, please contact [COBRA Administrator’s Name] at [Phone Number] or [Email].
[Signature of the Employer/Plan Administrator]
[Name of the Employer/Plan Administrator]
[Name of the Employee]
[Employee’s ID]
[Employee’s Address]
[Employee’s Phone]
[Employee’s Email]
[Name of the Employer/Plan Administrator]
[Employer’s ID]
[Employer’s Address]
COBRA Continuation Coverage Election Notice
This notice details your rights under COBRA to continue group health insurance coverage after a qualifying event. It provides necessary information about your options and responsibilities to ensure continuous coverage.
You may qualify for COBRA if you have experienced:
1. Job termination for any reason other than gross misconduct
2. A reduction in work hours leading to benefits loss
3. Spouse’s death
4. Divorce that results in the loss of coverage
5. Entitlement of the covered employee to Medicare.
Typically, COBRA coverage lasts for 18 months but may be extended for up to 36 months under certain circumstances, such as disability.
You have 60 days from the date of this notice or the qualifying event to notify us of your election, whichever is later.
You will need to pay the full premium for the COBRA coverage plus an allowable 2% administrative fee. Payment is due within 30 days after your election.
Please fill out the provided election form and send it to [Employer/Plan Administrator’s Address] by [Deadline Date].
For any questions regarding your rights or the election process, please reach out to [COBRA Administrator’s Name] at [Phone Number] or [Email].
[Signature of the Employer/Plan Administrator]
[Name of the Employer/Plan Administrator]
Format
Please complete the form below to create the COBRA Election Notice Template. All fields must be filled out to ensure compliance with COBRA regulations. We provide examples to guide you through each step. COBRA Election Notice Template 1. Employer Information 2. Plan Information 3. Qualified Beneficiary Information 4. Election Period 5. Coverage Information 6. Premium Payments 7. COBRA Rights 8. Contact Information for Assistance 9. Signature and Acknowledgment
PDF
WORD
Google Docs
Cobra Election Notice Template Printable | Editable FormPrintable
