COBRA FORM
General Notice
Generate COBRA Notification
Employer Information
Company Name
Street Address
Street Address 2
City
State
Zip
Phone Number
Contact Person
Employee Information
Employee Name
Street Address
Address Line 2
City
State
Zip
Date Group Coverage Ends
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2022
2023
2024
2025
2026
COBRA Information
Date of Notice
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2022
2023
2024
2025
2026
Qualifying Event
End of employment
Death of employee
Entitlement to Medicare
Reduction in working hours
Divorce or legal separation
Loss of dependent child status
Monthly rates
Medical
Dental
Vision
Employee
Spouse
Child(ren)
Automatically add 2% admin charge to rates