COBRA Qualifying Event Form

{BUSINESS NAME}

{ADDRESS}

{CITY, STATE, ZIP CODE}

Phone:   {NUMBER}    

Fax:   {NUMBER}

{EMAIL}

 

 

{DATE}

 

{EMPLOYEE NAME}

{ADDRESS}

{CITY, STATE, ZIP}

 

Re:   COBRA - Notice of Qualifying Event

 

Dear {EMPLOYEE NAME}

 

On {ENTER DATE OF QUALIFYING EVENT}, {DESCRIBE QUALIFYING EVENT}.   As a result, you and/or your dependents will no longer be covered under {BUSINESS NAME} employee health plan effective {DATE}.   You and/or your dependents are now eligible for continuation group health plan coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA).   Within the next {LENGTH OF TIME}, we will be sending you more information regarding COBRA, including a COBRA election form.   Please contact me at {INSERT INFORMATION} if you have any questions.

 

 

Sincerely,

 

 

 

{NAME}

{POSITION}

{BUSINESS NAME}