COBRA Qualifying Event Notification Form


COBRA Qualifying Event Notifications may be submitted electronically 24/7 through the secure Employer Portal. COBRA Specific Rights notices will generate on the next business day for events entered through the portal. 

COBRA Specific Rights Notices will be generated within 3 business days for qualifying events submitted using this notification form. For next business day generation please enter event through the employer portal.

All fields within this form with an asterix (*) by the field name are required for form submission.

Employer Information

Information regarding who we should contact if we have questions regarding the submitted form.

Contact Person Name*

Qualified Beneficiary (QB) Information

Information regarding the member experiencing the Qualifying Event

Qualified Beneficiary (QB) Name*
(optional) alternate Employee ID for reference/reports
QB Mailing Address*
Gender*
Date of Birth*

Event Information

COBRA events fall into either an Employee or Dependent category. This category establishes the length of continuation offered in the COBRA notice. 

If the employee and associated dependents are losing coverage, select Employee for the category.  If the employee is not the qualified beneficiary and is not losing coverage, select Dependent for the event category. 

Once the category is selected, choose the relevant event type from the resulting list. 

Qualifying Event Date:*
Date of Hire/Enrollment Date:*
Event Category:*

Termination – Voluntary: The member is no longer employed with the employer that provides the plan because the member resigned.

Termination – Involuntary: The member is no longer employed with the employer that provides the plan because the employer dismissed the member.

Termination with Severance: The member is no longer employed with the employer that provides the plan because the employer dismissed the member with compensation pay.

Reduction in Force: The member is no longer employed with the employer that provides the plan because the employer diminished its employees.

Reduction in Hours – Status Change: The member works less than full time for the employer that provides the plan for various reasons.

Retirement: The member is no longer employed with the employer that provides the plan because the member has concluded their career.

Loss of Eligibility: The member is no longer qualified to participate in the plan through their employer for various reasons.

Bankruptcy: The member is no longer qualified to participate in the plan through their employer because the employer legally declared financial insolvency.

Retiree Bankruptcy: The member is no longer qualified to participate in the plan through their employer because the member has concluded their career and the employer has legally declared financial insolvency.

Reduction in Hours – End of Leave: The member works less than full time for the employer that provides the plan because the member is on an authorized absence from their employment.

USERRA – Reduction in Hours: The member is not actively employed or employed less than full time with the employer that provides the plan because the member is performing military duty. The member's continued status as an employee of the employer is protected by the Uniformed Services Employment and Reemployment Rights Act (USERRA) which states that individuals performing military duty of more than 30 days may elect to continue employer sponsored health care for up to 24 months.

USERRA – Termination: The member is not actively employed or employed less than full time with the employer that provides the plan because the member is performing military duty. The member's continued status as an employee of the employer is protected by the Uniformed Services Employment and Reemployment Rights Act (USERRA) which states that individuals performing military duty of more than 30 days may elect to continue employer sponsored health care for up to 24 months.

Work Stoppage: The member is not actively employed with the employer that provides the plan because the member is part of a cessation of work by a group of employees as a means of protest.

Employee Name*
Is Employee Totally Disabled?*
Date of Disability
Is this a Qualified COVID19 Related Event?

Plans Information

The plan names entered below should be the specific plans assigned to the QB and should not be entered as just the carrier name or the just the designation of HMO or PPO. To ensure that the appropriate plans are assigned to the QB please enter the plan names as stated in your implementation or renewal plan confirmation.

Examples of appropriate plan names: BCBSTX Advantage Blue LDHP, DDMA Dental Plus PPO, EyeMed Vision

Plans to Include:*
Select all that apply
Should align with Medical
Need to Enter Additional Plans?*

Dependent Information

Additional family members to include in the Notification

Dependent Detail*
Dependent Child(ren) Detail:*

Spouse/Partner Information

Spouse / Partner*
Spouse/Partner Address:*
Spouse/Partner Gender
Spouse/Partner Date of Birth
Spouse/Partner Alternate Address*
Plans Assigned to Spouse/ Partner
Additional Plans Assigned to Spouse/ Partner

Dependent Child 1 Information

Dependent Child 1*
Child 1 Address:*
Child 1 Gender
Child 1 Date of Birth
Child 1 Alternate Address*
Plans Assigned to Child 1
Additional Plans Assigned to Child 1

Dependent Child 2 Information

Dependent Child 2*
Child 2 Address:*
Child 2 Gender
Child 2 Date of Birth
Child 2 Alternate Address*
Plans Assigned to Child 2
Additional Plans Assigned to Child 2

Dependent Child 3 Information

Dependent Child 3*
Child 3 Address:*
Child 3 Gender
Child 3 Date of Birth
Child 3 Alternate Address*
Plans Assigned to Child 3
Additional Plans Assigned to Child 3

Dependent Child 4 Information

Dependent Child 4*
Child 4 Address:*
Child 4 Gender
Child 4 Date of Birth
Child 4 Alternate Address*
Plans Assigned to Child 4
Additional Plans Assigned to Child 4

Dependent Child 5 Information

Dependent Child 5*
Child 5 Address:*
Child 5 Gender
Child 5 Date of Birth
Child 5 Alternate Address*
Plans Assigned to Child 5
Additional Plans Assigned to Child 5

Dependent Child 6 Information


Dependent Child 6*
Child 6 Address:*
Child 6 Gender
Child 6 Date of Birth
Child 6 Alternate Address*
Plans Assigned to Child 6
Additional Plans Assigned to Child 6

Subsidy/Severance Information

Subsidy Schedules are entered to reflect Severance agreements and other employer subsidies offered to the QB as part of a COBRA continuation arrangement. The amount entered is used to reduce the  premium amount due by the QB. 

Does a COBRA Subsidy or Severance apply to this event?*

Any combination of percentage and flat amount subsidies may be applied to continuation plans. 

If a QB is responsible for 20% of the $785.50 COBRA premium for a plan, the Amount would be entered as 80.00%

If a QB is responsible for $150 of the $785.50 COBRA premium for a plan, the Amount would be entered as $635.50

Medical Subsidy/Severance Information

Medical Subsidy Amount Type:*
Medical Subsidy Start Date:*
Medical Subsidy End Date:*

Dental Subsidy/Severance Information

Dental Subsidy Amount Type:*
Dental Subsidy Start Date:*
Dental Subsidy End Date:*

Vision Subsidy/Severance Information

Vision Subsidy Amount Type:*
Vision Subsidy Start Date:*
Vision Subsidy End Date:*

HRA Subsidy/Severance Information

HRA Subsidy Amount Type:*
HRA Subsidy Start Date:*
HRA Subsidy End Date:*

Additional Plan 1 Subsidy/Severance Information

Additional Plan 1 Subsidy Amount Type:*
Additional Plan 1 Subsidy Start Date:*
Additional Plan 1 Subsidy End Date:*
Progress
Form secured by Formstack
Form secured by Formstack
Cancel
Confirm