COBRA qualifying event notification

Submit a Notice of COBRA Qualifying Event when either of the following events occur:  (1) divorce or legal separation; or (2) qualifying child no longer meets the definition of dependent.  COBRA qualified beneficiaries have a right to elect continued coverage for up to 36 months.  To learn more, read the COBRA Notice inside the Plan Summary.

NOTE:  Carefully follow the Notification Procedures on the back side of the form.  To be valid, notice must be fully completed, signed, and received by the third-party administrator (TPA) no later than 60 days after the qualifying event. If your notice is late, incomplete, or is not submitted as instructed, no qualified beneficiary will be offered COBRA continuation coverage.