COBRA Notice of Qualifying Event

 

Company Name: Prepared By: Information on the Primary Qualified Beneficiary (PQB): In the event of an employee experiencing a Qualifying Event, the PQB is the employee. If the Qualifying Event and the loss of coverage occurs to a spouse or child, they are the PQB. SSN: PQB Name: PQB Mailing Address   Address Line:   City:   State:   Zip: Gender: --- Please Select --- Male Female Phone: E-mail Address: Date of Birth: Marital Status: --- Please Select --- Single Married Divorced Legal Separation Date of Hire: Original Effective Date of Coverage: Date of Qualifying Event (QE): Premium Paid Through Date: Notified Carrier Date: Description of QE --- Please Select --- Termination Death of employee Divorce or legal separation* Employee's Medicare Entitlement Leave of Absence Loss of coverage Loss of dependent status* Reduction in hours Social Security Disability* Other   *send documentation of event; in the case of Social Security Disability, send SSA determination letter which needs to be submitted within 60 days from the date of the determination. If other, specify:   Type of Coverage in effect prior to QE: --- Please Select --- Employee Only Employee & Spouse Employee & Children Employee & Family Benefits in effect prior to QE: Medical Dental   HMO   DMO   PPO   PPO   Other   Other Vision Other Section 125 / FSA Monthly Contribution Family Members on COBRA - If they are not a  Qualified Beneficiary, please note. First Name: If last name is different, asterisk and indicate at the bottom SSN Relation Gender DOB Address if Different -------- Spouse Child -------- Male Female -------- Spouse Child -------- Male Female -------- Spouse Child -------- Male Female -------- Spouse Child -------- Male Female -------- Spouse Child -------- Male Female -------- Spouse Child -------- Male Female *Last Name: Comments:

11118 Wurzbach Road, Suite 300 / San Antonio, Texas 78230 / 210.558.0999 / Fax 210.641.7771