COBRA Qualifying Event Notice

Please complete the form below and submit (using the button at the bottom of the page) to initiate the COBRA Notification process for the qualified beneficiaries.

Employer Section

Employer:

Completed by:

Preparer E-mail Address:*

Date:

Format: MM/DD/YYYY (numeric entry only)

Event Description

Event Date:

Format: MM/DD/YYYY (numeric entry only)

Event Type:

Voluntary - Retired or resignedInvoluntary - Other than gross misconductInvoluntary - Gross misconduct

Covered Thru

Format: MM/DD/YYYY (numeric entry only)

Employee/Dependent Section

Employee Name:

First NameLast Name

Address:

Phone Number

Employee E-mail Address:

Date of Birth:

Format: MM/DD/YYYY (numeric entry only)

SSN:

Format: ###-##-####

Plan Section

FSA Participant:

YesNo

Medical Carrier:

Coverage (select one):

EEECESFAM

Group Number:

Plan Option:

Dental Carrier:

Coverage (select one):

EEECESFAM

Group Number:

Plan Option:

Vision Carrier:

Coverage (select one):

EEECESFAM

Group Number:

Plan Option:

* Note: Insurance coverage cannot be bound or changed via submission of any online form/application provided on this site or otherwise. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly by a licensed agent.

Please check the box to verify.*