Editor's Note: In response to the COVID-19 pandemic, the U.S. Department of Labor (DOL) released a new final rule that temporarily extends the period in which eligible employees can elect COBRA health insurance coverage, and the deadline for them to begin making COBRA premium payments. See DOL Temporarily Extends COBRA Deadlines and Agencies Revise—and Complicate—COBRA Deadline Extensions.
Employee name ___________________________________________
Qualifying event ___________________________________________
Qualifying event date _______________________________________
COBRA start date __________________________________________
COBRA end date ___________________________________________
☐ Initial COBRA notification letter mailed to employee. Date ________
☐ Initial COBRA notification letter mailed to spouse/dependents. Date ________
☐ Notice of qualifying event received. Date ________
☐ Insurance carrier notified of cancellation of coverage. Date ________
☐ Election notice mailed to employee and covered dependents. Date ________
☐ Election form received from employee and covered dependents. Date ________
☐ Initial COBRA premium received for selected coverage. Date ________
☐ COBRA coverage exhausted or terminated. Date ________
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