COBRA Initial Notification Form

{BUSINESS NAME}

{ADDRESS}

{CITY, STATE, ZIP CODE}

Phone:{NUMBER}

Fax:{NUMBER}

{EMAIL}

{DATE}

{EMPLOYEE NAME}

{ADDRESS}

{CITY, STATE, ZIP}

RE: Initial Notification - COBRA

Dear {EMPLOYEE NAME}

The Consolidated Omnibus Budget Reconciliation Act of 1985 provides continuation health coverage to qualified employees and their dependents after certain qualifying events, which would have otherwise ended their coverage.Before COBRA was signed into law in 1986, those employees and their dependents would have likely lost their group health plan coverage or been forced to pay for individual health coverage, which is generally more expensive.

In accordance with federal law, {BUSINESS NAME} must notify employees and their dependents of their future rights under COBRA when those employees and dependents begin their coverage under our group health care plan.This letter provides a summary of those rights.   If you and/or your dependents become eligible for COBRA coverage, our Plan Administrator will send you more comprehensive information.

Please read the enclosed information carefully and keep it in your files for future reference.  Any questions you may have can be directed to {PLAN ADMINISTER NAME} our Plan Administrator, who can be contacted at {INSERT CONTACT INFORMATION}.

Sincerely,

{NAME}

{POSITION}

{BUSINESS NAME}