Set of COBRA Forms

The forms and documents included here are:

COBRA Administrative Procedures – This document provides a listing of administrative guidelines that are important considerations for the administration of COBRA benefits. This is a priceless summary of COBRA information, whether you administer COBRA directly or you use an outside firm.
COBRA Checklist – This is an invaluable checklist for you to use and keep in an employee’s “Confidential – Supervisor Restricted” file to ensure that you complete your legal and administrative obligations related to COBRA. This checklist allows you to record your compliance with the COBRA guidelines when an employee and/or an employee’s spouse or dependents have a Qualifying Event under COBRA regulations. This form is to be completed for each Qualifying Event to ensure that you have followed proper procedures.
COBRA Continuation Election Form – This is the form to be sent to an employee or spouse when a Qualifying Event occurs along with a “COBRA Qualifying Event Notice.”
HIPAA Certification of Health Coverage – When an employee or an employee’s spouse or dependent ends his/her coverage under a COBRA eligible plan, this form needs to be completed and mailed to the person in case the person seeks health coverage under another plan. This document is poof of the person’s previous health coverage which is designed to prevent the new plan from disqualifying the person based on any pre-existing conditions when the individual joins that new plan.
COBRA New Employee Notice – When a new employee joins your company and selects COBRA eligible insurance, this form is to be sent to the new employee. This form is also to be sent to the new employee’s spouse.
COBRA Qualifying Event Chart – This is a quick reference chart for you to use when trying to make COBRA related decisions.
COBRA Qualifying Event Notice – This is the form to be sent to an employee or spouse when a Qualifying Event occurs along with a “COBRA Continuation Election Form.”
COBRA Termination for Non-Payment Letter – This is a sample letter to use when notifying a person on COBRA about the pending termination of COBRA eligible insurances for non-payment. Be sure to review the guidelines in the file “COBRA Administrative Procedures” before taking any final action to terminate a person for non-payment as the COBRA rules are very specific about when and how to terminate benefits for non-payment of premiums.

Non-Member Investment: $125.00
Member: $100.00 (20% Savings)

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