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COBRA Qualifying Event Notification Form Step 1: Qualified Beneficiary Information *Required Fields×Employer Name (Do not abbreviate)*Birth Date (mm/dd/YYY)*Participant Name (First, MI, Last)*Social

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How to fill out cobra qualifying event notification

01

To fill out a COBRA qualifying event notification, follow these steps:

02

Obtain the COBRA qualifying event notification form from your employer or insurance provider.

03

Fill out your personal information, such as your name, address, and contact information.

04

Provide details about the qualifying event that makes you eligible for COBRA coverage, such as your termination date or reduction in work hours.

05

Indicate whether you would like to elect COBRA coverage for yourself only or for yourself and any eligible dependents.

06

Sign and date the form to verify the accuracy of the information provided.

07

Submit the completed COBRA qualifying event notification form to your employer or insurance provider within the specified timeframe.

08

Keep a copy of the form for your records.

Who needs cobra qualifying event notification?

01

Anyone who experiences a qualifying event that makes them eligible for COBRA coverage needs to submit a COBRA qualifying event notification. Qualifying events may include job loss, reduction in work hours, divorce or legal separation, death of the covered employee, or aging out of dependent status.

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