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2019 COBRA Notices
COBRA Notice Generator
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Denotes this notice is mandatory and must be sent within a certain time frame. More on time frames.
Send when coverage is lost due to a termination of employment, reduction in hours, death, or divorce/legal separation.
Sometimes referred to as the "New Hire" Notice. Send within 90 days of the date the employee first becomes covered.
Send when coverage is lost due to a termination of employment, reduction in hours, death, or divorce/legal separation. New York Version. For use by New York based employers with New York issued health plans.
California
COBRA Qualifying Event Notice
12 page summary of the COBRA rules. Can be provided to employees or used as a reference.
Send when coverage is lost due to a termination of employment, reduction in hours, death, or divorce/legal separation. New York Version. For use by California based employers with California issued health plans.
Send if someone requests, but is not eligible for COBRA. For example, the individual was not covered on the plan when they were terminated from employment. In this case, they are not entitled to COBRA.
Send Within
The plan administrator must provide the notice within 14 days after receiving a notice of qualifying event from a participant, beneficiary or other individual
Individuals use this form to request an 11-month Social Security Disability Extension.
In order to be eligible for the 11-month disability extension, the individual must be disabled on or before the first 60 days of COBRA coverage and provide the Social Security Disability Determination letter prior to the end of the 18 month COBRA period.
This notice advises the individual that COBRA will end and to contact the carrier to determine if there is an option to convert COBRA to an individual plan.
Send within 180 days of the date COBRA will end.

This is a letter that notifies a participant and/or beneficiary on COBRA continuation coverage that his or her coverage will be terminating earlier than the end of the maximum coverage period of COBRA coverage applicable to a qualifying event.

No set time frame.
Send along with open enrollment materials to advise a qualified beneficiary they can make changes during open enrollment.
Send to COBRA enrollee advising them that their COBRA election has been received.
Send to COBRA enrollees to advise them that their payment is either short the full amount or the check was returned NSF.
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Sometimes called the "New Hire" notice, the Initial Notice must be sent within 90 days of the date the individual first becomes covered under the plan. A single notice, addressed to the covered employee, spouse and dependent living at the same address is sufficient.
 
Qualifying Event Notices must be sent with 44 days of the qualifying event date when the employer is also the plan administrator. The rule is "the employer has 30 days to notify the plan administrator. The plan administrator then has 14 to to send the notice. When the employer is the plan administrator, they have the entire 44 days to send the notice.