COBRA BENEFIT TERMINATION FORM
Please use the form below to communicate when an employee or former employee is entitled to continuation coverage.
Please forward the completed form as follows:
Cobra Benefit Termination Form
Via mail: 3819 Market Street, Camp Hill, PA 17011
Via email: firstname.lastname@example.org
Via fax: (717) 975-9303
The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers and their families who lose their health benefits the right to choose to continue group health benefits for a limited period of time. If you, as an employer, have 20 or more employees you must offer COBRA benefits to the employee who leaves your company. As a matter of fact, there are several qualifying events under which an employee could claim this benefit. They are:
- Voluntary or involuntary job loss
- Reduction in hours worked
- As a transition between employment
- Death of a loved one
- Spousal loss of benefits
- Loss of “dependent child” status
COBRA administration outlines how employees and family members may elect to continue with group health coverage. The law also requires employers to provide notice of this plan.
The Department of Labor outlines specific processes to follow when applying for and administrating COBRA benefits. An employer must be aware of this process and be versed in items such as availability of health plans, compliance, portability of health coverage, etc. For additional information, please visit the U.S. Department of Labor website – www.dol.gov.
Capital Region Benefits has refined the COBRA process. We can:
- Answer your questions regarding any qualifying event
- Administer and track your COBRA notifications
- Invoice your COBRA accounts
- Handle any claim issues
- Clarify any RX questions the employee may encounter
With 20 years of experience, we would be happy to administer COBRA benefits for you.