2019 COBRA Notices
COBRA Notice Generator
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.
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.
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.