COBRA NOTIFICATION FORM
Employer:
Type of Qualifying Event
(Please check one event. If there is a termination of a Medicare covered employee then choose the last selection)
Death of Covered Employee
Termination of Covered Employee (other than by reason of gross misconduct) This includes
Voluntary termination of employment by employee
Reduction of Hours of Covered Employee
Divorce or Legal Seperation of Covered Employee
Covered Employee's Entitlement to Medicare Benefits
Disabled Individual who has sent notice of his/her Social Security
Disabilty Determination
Dependent Child ceasing to be a Dependent under the Plan's Terms
Termination of Covered Employee / Covered Employee's Entitlement to Medicare Benefits
Date of Qualifying Event:
Date of Premium Paid Through:
Covered Employee Name:
Address:
City:
State:
Zip Code:
Social Security Number:
Date of Birth:
Date of Hire:
Effecitve Date:
Employee Currently Covered by Medicare:
Yes
No
Unknown
Name of Covered Spouse or Domesitc Partner:
Address:
City:
State:
Zip Code:
Social Security Number:
Date of Birth:
Name of Covered Dependents:
Address:
City:
State:
Zip Code:
Employee is Currently Covered and Entitled To:
Medical:
Single
Single+Sp
Single+Ch
Family
Dental:
Single
Single+Sp
Single+Ch
Family
Vision:
Single
Single+Sp
Single+Ch
Family
Please note that the Employer is responsible for terminating coverage with the insurance carriers.
EBA will notify the employer if and when to reinstate coverage.
Plan Administrator Signature:
Date:
Administrator Title:
Administrator Email:
EBA OFFERS 401k ROLLOVER SERVICE. PLEASE INDICATE IF YOU WOULD LIKE AN
EBA REPRESENTATIVE TO CONTACT THIS INDIVIDUAL REGARDING THEIR 401k.
Yes, Please contact the individual:
Signature:
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