Employee Benefits - COBRA Compliance

Your Name

Employer Name

Email


Add additional email address(es)

Employee's Name

Gender
-- Select --FemaleMale

Employee's Social Security

Home Address

Apt/Unit No.

City

State
-- Select State --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands

Postal Code

Date of Birth

Date of Hire

Date Benefit Coverages Originally Began

Date Qualifying Event Happened
(Please use the date that event actually happened, not the date that the change is effective)

Type of Qualifying Event
--Select--Involuntary TerminationVoluntary ResignationReduction of Work HoursEmployee DeathDivorce or Legal SeparationLoss of Dependent StatusMedicare EntitlementRetirement

Send Notice In
-- Select --EnglishSpanish

Plans Enrolled In
MedicalDentalVisionChiropractic / OtherFlexible Spending Plan

Do they have Covered Children?
YesNo

Do they have a Covered Spouse or Domestic Partner?
YesNo

Please Include Any Additional Notes

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