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COBRA Forms

COBRA Model Notices

COBRA Forms

In order to stay in compliance with COBRA and ARRA laws, employers and plan administrators must provide very specific COBRA forms to current and former employees as well as their beneficiaries to inform them of their rights under COBRA. As an employer, it is important to understand what these COBRA notices look like and contain to make sure that you are in full compliance with the law. As an employee, it is important to understand COBRA forms to make sure your company/plan s providing you with the proper paperwork so that you can enroll in coverage. It can also be helpful to look at these sample COBRA insurance forms when you are filling out any paperwork from your employer.

General COBRA Notice

This notice is used to inform the employee and/or beneficiary of their rights to federal COBRA coverage after a qualifying event. The form will normally contain exactly what the qualifying event was and who is eligible for coverage. Then the form will contain the enrollment paperwork that must be completed within 60 days of the date of the notice. The form normally also contains the cost of COBRA for the entire family and also broken down by individual.

Download: General COBRA Notice (203 KB)

Notice of New Election Period

In the event that there is a new election period for COBRA, normally due to a second qualifying event, then the employer/plan administrator must provide the employee and/or beneficiaries with a second election notice within 60 days of the event.

Download: Notice of New Election Period (202 KB)

Supplemental Information Notice

In the event that there is a change to the federal law regarding COBRA, then the employee and beneficiary must be provided with a supplemental information notice for COBRA. This supplemental notice will contain any important changes and how it will impact their coverage.

Download: Supplemental Information Notice (187 KB)

Notice of Extended Election Period

In the event that an employee or beneficiary qualifies to extend their COBRA benefits beyond the typical 18 or 36 months, the plan administrator must inform them of their rights for continuation and provide them with a COBRA form to extend enrollment if they choose. This form indicates the cause for extension as well as the length of time.

Download: Notice of Extended Election Period (208 KB)

Updated Alternative Notice

This notice must be provided to employees and beneficiaries if the insurance company providing group coverage is subject to comparable continuation coverage requirements as written in the state law. Every state has specific laws regarding when this notice must be provided.

Download: Updated Alternative Notice (166 KB)


As is the case with any sample COBRA form, these forms should be used as examples only and should be adapted to fir the needs of your business, insurance plan, and situation. Given the complex legal compliance issues of COBRA it is always smart to consult an expert when crafting your COBRA notices.

* COBRA Forms provided by the United States Department of Labor

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