New COBRA Notices

The American Recovery & Reinvestment Act includes a provision providing that employees, whose employment involuntarily terminated between September 1, 2008 and December 31, 2009, and their eligible dependents may qualify for a subsidy of their COBRA premiums equal to 65% of the cost.  Thus, qualifying individuals pay only 35% of the premium cost and employers subsidize the remaining 65%.  The federal government reimburses employers by allowing them to deduct the cost of the employer’s 65% share of the COBRA premium from their federal employee tax contributions.

Below are three sets of sample forms issued by the U.S. Department of Labor that employers can use to:
  1. Notify eligible participants who have not received a prior COBRA notice.
  2. Notify eligible participants who previously received a COBRA notice.
  3. For employers with fewer than 20 employees, who are not covered by COBRA.
For your convenience we highlighted in yellow each place on each form where you need to customize it for your company or organization. 

Each of the sets includes a primary Notice and additional forms, as follows:

1.  Model COBRA Continuation Coverage Election Notice

This Notice may be used for any employee, former employee or beneficiary who has not yet received any COBRA notice.  Accompanying forms include:
  • COBRA Continuation Coverage Election Form
  • Form for Switching COBRA Continuation Coverage Benefit Options
  • Important Information About Your COBRA Continuation Coverage Rights
  • Summary of the COBRA Premium Reduction Provisions under ARRA
  • Request For Treatment As An Assistance Eligible Individual
  • Participant Notification

>> Please click here to access the form.

2.  Model COBRA Continuation Coverage Additional Election Notice

This Notice may be used for former employees and qualified beneficiaries who are or would be eligible for the subsidy but are not enrolled in COBRA coverage (including those who did not previously elect COBRA and those who previously elected but subsequently discontinued coverage) and who experienced an involuntary loss of employment during the period from September 1, 2008 through February 16, 2009.  Accompanying forms include:
  • COBRA Continuation Coverage Election Form
  • Form for Switching COBRA Continuation Coverage Benefit Options
  • Important Information About Your COBRA Continuation Coverage Rights
  • Summary of the COBRA Premium Reduction Provisions under ARRA
  • Request for Treatment as an Assistance Eligible Individual
  • Participant Notification

>>Please click here to access the form.

3.  Model Continuation Coverage Election Notice (Less than 20 employees)

This Notice may be used by employers with less than twenty (20) employees, where coverage is subject to State continuation requirements such as New Jersey mini-COBRA, during the period that begins with September 1, 2008 and ends with December 31, 2009.  Accompanying forms include:
  • Continuation Coverage Election Form
  • Form for Switching Continuation Coverage Benefit Options
  • Important Information about Your Continuation Coverage Rights
  • Summary of the Continuation Coverage Premium Reduction Provisions under ARRA
  • Request for Treatment as an Assistance Eligible Individual
  • Participant Notification

>>Please click here to access the form.

If you have any questions regarding COBRA or these forms, or need any help, please contact Douglas S. Zucker at DSZ@zuckerhatfield.com or Kathryn V. Hatfield at KVH@zuckerhatfield.com.