COBRA Overdue Payment Form

{BUSINESS NAME}

{ADDRESS}

{CITY, STATE, ZIP CODE}

Phone:   {NUMBER}    

Fax:   {NUMBER}

{EMAIL}

 

 

 

{DATE}

 

 

{EMPLOYEE NAME}

{ADDRESS}

{CITY, STATE, ZIP}

 

 

Re:   COBRA - Overdue Payment

 

 

 

Dear {EMPLOYEE NAME}

 

We have not received your COBRA payment for {ENTER PERIOD}.   If payment is not received by {DATE}, your coverage will be terminated.   If you intend to continue coverage, please send your payment as soon as possible.   If we do not hear from you, we will assume it is your intention to cancel coverage, and your coverage will be cancelled effective {DATE}. If you have any questions please contact {PLAN ADMNISTRATOR NAME}, our plan administrator, at {ENTER CONTACT INFORMATION}.

 

Sincerely,

 

 

 

{NAME}

{POSITION}

{BUSINESS NAME}