Employee Benefits - COBRA Compliance QUALIFYING EVENT COMPLETE THE FOLLOWING Your Name Employer Name Email Add additional email address(es) Additional Email (if adding multiple emails, separate by commas.) 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 Name Of Medical Plan: Medical Coverage: Employee OnlyEmployee & SpouseEmployee & ChildEmployee & ChildrenEmployee & Family Monthly Premium For Medical Plan: Name Of Dental Plan: Dental Coverage: Employee OnlyEmployee & SpouseEmployee & ChildEmployee & ChildrenEmployee & Family Monthly Premium For Dental Plan: Name Of Vision Plan: Vision Coverage: Employee OnlyEmployee & SpouseEmployee & ChildEmployee & ChildrenEmployee & Family Monthly Premium For Vision Plan: Name Of Other Plan: Other Coverage: Employee OnlyEmployee & SpouseEmployee & ChildEmployee & ChildrenEmployee & Family Monthly Premium For Other Coverage: Monthly Amount of FSA CONTRIBUTION Do they have Covered Children? YesNo Do they have a Covered Spouse or Domestic Partner? YesNo Full Names and Birth Dates of All Covered Children Spouse Name Spouse Date of Birth Does Either Spouse or Children Have a Different Home Address? If yes, please show address in additional notes. -- Select --YesNo Please Include Any Additional Notes Δ Request a Quote For... AUTO & VEHICLE HOME & PROPERTY BUSINESS SERVICES EMPLOYEE BENEFITS About UA My UA Portal Request A Quote Employee Benefits COBRA HR Link OSHA Newsletter Payments Contact Us