COBRA Qualifying Event Notice (Employer to Plan Administrator)

NOTICE OF COBRA QUALIFYING EVENT

From Employer to Plan Administrator

1. DELIVERY INFORMATION

Date of This Notice: [__/__/____]

Method of Delivery: ☐ First-class U.S. mail ☐ Certified mail, return receipt requested ☐ Hand delivery ☐ Electronic (only if the DOL safe harbor at 29 C.F.R. § 2520.104b-1(c) is met) ☐ Other: [________________________________]

From (Employer):

To (Plan Administrator):

2. STATUTORY BASIS AND TIMING

This notice is furnished under ERISA § 606(a)(2), 29 U.S.C. § 1166(a)(2), and 29 C.F.R. § 2590.606-2, which require the employer to notify the plan administrator of a qualifying event described in ERISA § 603(2), (4), or (6) within thirty (30) days after the later of:

(a) the date of the qualifying event; or

(b) if the plan provides that continuation coverage and the obligation to pay premiums begin on the date of loss of coverage, the date on which coverage is lost.

Date of qualifying event: [__/__/____]

Date coverage will be (or was) lost, if different: [__/__/____]

Day 30 deadline for this notice (calculated): [__/__/____]

3. COVERED EMPLOYEE INFORMATION

4. QUALIFYING EVENT

Check the applicable qualifying event(s) under ERISA § 603, 29 U.S.C. § 1163:

☐ Termination of employment (other than by reason of gross misconduct) — § 1163(2)

☐ Reduction in hours of the covered employee's employment — § 1163(2)

☐ Death of the covered employee — § 1163(1)

☐ Divorce or legal separation of the covered employee — § 1163(3)

☐ Covered employee's entitlement to Medicare (Title XVIII of the Social Security Act) — § 1163(4)

☐ Dependent child ceasing to be a "dependent child" under plan terms — § 1163(5)

☐ Employer bankruptcy (Title 11) affecting retiree coverage — § 1163(6)

Event marked as: ☐ Statutory employer notice under § 1166(a)(2) ☐ Informational / courtesy forwarding of a qualified beneficiary notice

5. ADDITIONAL FACTS RELEVANT TO THE EVENT

If termination or reduction in hours:

• Last day actively at work: [__/__/____]
• Last day of active coverage: [__/__/____]
• Gross misconduct alleged? ☐ No ☐ Yes (if yes, coverage may not be a qualifying event; attach written basis): [________________________________]
• Severance arrangement that subsidizes or extends active coverage? ☐ No ☐ Yes — describe: [________________________________]

If Medicare entitlement:

• Date of Medicare entitlement: [__/__/____]
• Part A, Part B, or both: [________________________________]

If death of covered employee:

• Date of death: [__/__/____]
• Surviving qualified beneficiaries notified employer on: [__/__/____]

If divorce or legal separation:

• Date of decree / order: [__/__/____]
• Court and case number: [________________________________]

If dependent child losing dependent status:

• Date child ceased to qualify: [__/__/____]
• Basis (age-out, marriage, etc.): [________________________________]

If employer bankruptcy:

• Petition date: [__/__/____]
• Chapter: [____]
• Case number and court: [________________________________]

6. QUALIFIED BENEFICIARIES

Identify each individual who was covered under the plan on the day before the qualifying event and who is therefore a qualified beneficiary under ERISA § 607(3), 29 U.S.C. § 1167(3). Add rows as needed.

7. PLANS AFFECTED

Identify every group health plan / component benefit under which the covered employee and any qualified beneficiary had coverage on the day before the qualifying event:

☐ Major medical — carrier / TPA: [________________________________] — Group #: [____________]

☐ Dental — carrier: [________________________________] — Group #: [____________]

☐ Vision — carrier: [________________________________] — Group #: [____________]

☐ Health FSA — balance status as of event date: [________________________________]

☐ HRA — [________________________________]

☐ Employee Assistance Program (if it provides medical care): [________________________________]

☐ Wellness program (if it provides medical care): [________________________________]

☐ Other: [________________________________]

8. MAXIMUM COVERAGE PERIOD (TO ASSIST ADMINISTRATOR)

As a courtesy to the plan administrator, the applicable maximum coverage period under ERISA § 602(2), 29 U.S.C. § 1162(2), appears to be:

☐ 18 months — termination of employment or reduction in hours

☐ 29 months — termination / reduction in hours plus timely Social Security disability determination (extension on qualified beneficiary notice)

☐ 36 months — death, divorce / legal separation, Medicare entitlement, or loss of dependent status

☐ Other / indeterminate — explain: [________________________________]

9. PREMIUM INFORMATION

10. SUPPORTING DOCUMENTS ATTACHED

☐ Copy of termination letter or status-change form

☐ Copy of divorce decree / legal separation order (redacted as appropriate)

☐ Death certificate (redacted as appropriate)

☐ Medicare entitlement documentation

☐ Dependent status change documentation

☐ Most recent enrollment record for the covered employee and dependents

☐ Other: [________________________________]

11. CERTIFICATION

I certify that I am authorized by the employer identified in Section 1 to deliver this notice; that the information above is true and correct to the best of my knowledge after reasonable inquiry; and that this notice is being delivered within the time required by ERISA § 606(a)(2) and 29 C.F.R. § 2590.606-2.

Signature: [________________________________]

Printed name: [________________________________]

Title: [________________________________]

Date: [__/__/____]

12. PLAN ADMINISTRATOR RECEIPT (FOR ADMINISTRATOR'S USE)

Received on: [__/__/____] By: [________________________________]

14-day election-notice deadline (29 C.F.R. § 2590.606-4(b)(2)): [__/__/____]

Sources and References

• ERISA § 603, 29 U.S.C. § 1163 — Qualifying event: https://www.govinfo.gov/app/details/USCODE-2024-title29/USCODE-2024-title29-chap18-subchapI-subtitleB-part6-sec1163
• ERISA § 606, 29 U.S.C. § 1166 — Notice requirements: https://www.govinfo.gov/app/details/USCODE-2024-title29/USCODE-2024-title29-chap18-subchapI-subtitleB-part6-sec1166
• IRC § 4980B — Failure to satisfy COBRA continuation requirements: https://www.govinfo.gov/app/details/USCODE-2024-title26/USCODE-2024-title26-subtitleD-chap43-sec4980B
• 29 C.F.R. § 2590.606-2 — Notice requirements for plan administrators (employer notice of qualifying event): https://www.ecfr.gov/current/title-29/part-2590/section-2590.606-2
• 29 C.F.R. § 2590.606-4 — Notice requirements for plan administrators (election notice to qualified beneficiaries): https://www.ecfr.gov/current/title-29/part-2590/section-2590.606-4
• U.S. Department of Labor, "An Employer's Guide to Group Health Continuation Coverage Under COBRA": https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-activities/resource-center/publications/an-employers-guide-to-group-health-continuation-coverage-under-cobra.pdf
• IRS Treas. Reg. § 54.4980B-1 et seq. — parallel tax-side COBRA regulations: https://www.ecfr.gov/current/title-26/chapter-I/subchapter-D/part-54

Drafting Notes

• Who sends this. The employer (or plan sponsor) sends this notice when the employer is not also the plan administrator. Where the employer is the plan administrator, the statutory employer-to-administrator notice collapses into the single 44-day election-notice deadline measured from the qualifying event (29 C.F.R. § 2590.606-4(b)(2)), and this form becomes an internal documentation record rather than an external notice.
• Penalty exposure. IRC § 4980B imposes an excise tax of $100 per qualified beneficiary per day of noncompliance (capped at $200/day per family); ERISA § 502(c)(1) authorizes up to $110/day statutory penalties for plan-administrator notice failures (as adjusted). Missing the 30-day employer notice is the most common root cause of downstream election-notice failures.
• Multiemployer plans. Multiemployer plan documents may specify a longer employer notice period under 29 C.F.R. § 2590.606-2(b)(2). Check the plan document.
• State "mini-COBRA." This notice addresses only federal COBRA (applicable to employers with 20+ employees on a typical business day in the preceding calendar year, 29 U.S.C. § 1161(b)). If the employer is below the federal threshold, use the applicable state continuation-coverage notice instead (e.g., Cal. Ins. Code §§ 10128.50 et seq.; N.Y. Ins. Law § 3221(m); Tex. Ins. Code § 1251.252; Fla. Stat. § 627.6692).
• Electronic delivery. Electronic delivery to the plan administrator is acceptable only if it meets the DOL safe harbor at 29 C.F.R. § 2520.104b-1(c) (integrated into work duties and access, or affirmative consent). Default to paper with proof of mailing when in doubt.