COBRA Election Notice Form
Employer/Plan Information
Employer/Plan Sponsor Name
Plan Name
Employer/Plan Sponsor Address
Phone Number
Qualified Beneficiary Information
Qualified Beneficiary Name
Address
Date of Birth
SSN (last 4 digits)
Qualifying Event Information
Type of Qualifying Event
Date of Qualifying Event
COBRA Coverage Details
Start Date of COBRA Coverage
End Date of COBRA Coverage
Monthly Premium Amount
Payment Due Date
Instructions
Instructions to Qualified Beneficiary
Contact Information
Contact Name
Contact Phone
Contact Email
Notes