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Model COBRA Continuation Coverage Election Notice. Instructions. The Department of Labor has developed a model Consolidated Omnibus Budget 10 Jun 2008 Sample COBRA Notice. ABC Company c/o The COBRA Administrator's Name . elect coverage by the date specified on the Election Form. 22 Aug 2014 The COBRA Model Election Notice was revised to inform qualified beneficiaries of coverage options available through government-run health Flexible Spending Account COBRA Election Form. Date //______. QUALIFIED BENEFICIARY INFORMATION. Last Name COBRA Election (or Refusal) Form. Date Employee Name. Address. On (date) your group coverage, including dependents, in the (employer name) group plan Sample election Notice (covered employee's termination of employment or reduction of hours)1. COBRA requires that a COBRA continuation coverage election COBRA Continuation Coverage Election Form. Form completion instructions: This notice must be sent to the plan participants and beneficiaries by first class mail RE: NOTICE OF RIGHT TO ELECT COBRA CONTINUATION COVERAGE. It is important that all covered individuals read this notice. Notification to the covered. Model COBRA Continuation Coverage Election Notice. (For use by single-employer group health plans). [Enter date of notice]. Dear: [Identify the qualified If you choose to elect COBRA continuation coverage, you should use the election form provided later in this notice. If your coverage ends for any of the following
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