COBRA Personnel Action Report

Employer: Phone: Branch #:
Employee:
Last: First: Middle:
Date of Hire
 (mm/dd/yy) 		       
Qualifying Event Type:
Is this a Secondary Qualifying Event? Yes  No
Original Qualifying Event Date:
 
How was employer notified? 		   
  Mail    
  Phone    
  In Person    
  Other: By Whom?

Date employer received notice:  Today's date:

Primary Qualifying Beneficiary (PQB)

Last:   First: Middle:
Street:  
City:    State:   Zip:  
SSN:    D.O.B. Sex: Male  Female

Present Plan Benefits

Present Eligibility Criteria

 Date present plan
benefits terminate:
  Medical Dental Vision FSA
Eligible Employee Only

Eligible Employee & Spouse
Employee & Family
Employee & Children

Family Information (if currently covered)

Name (last, first, middle):
Spouse: D.O.B.: Sex:   SSN:
Child 1: D.O.B.: Sex:   SSN:
Child 2: D.O.B.: Sex:   SSN:
Child 3: D.O.B.: Sex:   SSN:
Child 4: D.O.B.: Sex:   SSN:
Message (optional):
    
     
Completed by:   Date:


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