COBRA Election Notice Form
Employer Name
Plan Administrator Name
Plan Name
Qualifying Event
Date of Qualifying Event
Date Coverage Ends
Participant Information
Employee Name
Spouse Name
Dependent(s)
Address
COBRA Coverage Details
Coverage Available
Total Monthly Cost
Maximum Coverage Period (months)
Important Deadlines
Date Notice Sent
Last Day to Elect COBRA
Instructions and Additional Information
Instructions for electing COBRA continuation coverage
Payment instructions and deadlines
Contact information for questions
Other required notices or disclosures
Signatures
Signature (Plan Administrator)
Date