COBRA Qualifying Event Form 1. Company:* 2a. Qualified Beneficiary is:* Employee Dependent 2b. This form is the:* Original Revision 3. Social Security Number of Qualified Beneficiary:* 4. Name of Qualified Beneficiary(last, first, mi):* 5. Address*Street Address Address Line 2Address Line 2 City*City State*State ZIP Code*ZIP Code 6. Home Phone7. Date of Birth:* Month Day Year 8. Gender* Male Female 9. Marital Status* Single Married Widowed Divorced 10. If the qulified beneficiary indicated in #4 is a dependent, please complete the following:Employee Name (last, first, MI) Employee's SSNEmployee's SSN Relationship to BeneficiaryRelationship to Beneficiary 11. Qualifying Event that caused loss of coverage (check one below):Continuation of coverage for 18 months for Federal COBRA or 9 months for PA Mini-COBRA: Employee's involuntary termination of employment (except when due to gross misconduct) Employee's termination due to Gross Misconduct: employer WILL Extend COBRA Employee's termination due to Gross Misconduct: employer WILL NOT Extend COBRA Employee's voluntary resignation of employement Employee's voluntary termination of employment Employee's voluntary retirement of employment Employee's layoff Employee's leave of absence Employee's reduction in work hours (includes work stoppage or strike) Other (please describe): Continuation of coverage for 36 months for Federal COBRA or 9 months for PA Mini-COBRA:Continuation of coverage for 36 months for Federal COBRA or 9 months for PA Mini-COBRA: Death of covered employee/retiree Divorce / legal separation Covered employee / retiree becomes entitled to Medicare; dependents may elect continuation Ineligibility of dependent child (child has "aged out") Retiree, spouse or child of retiree loses coverage within one year before or after commencement of proceedings under title 11(bankruptcy) 11a. Qualifying Event Date*(The date 11 happened) MM slash DD slash YYYY 12. Last day of pre-COBRA coverage (the last day on regular group coverage):* 13. First premium due-date for which AIA Alera will begin billing the COBRA Beneficiary:* 14. In what lines of coverage was the beneficiary enrolled?* Health Dental Vision Other Life/AD&D STD LTD Worksite 15. For each line of coverage, indicate in which coverage tier the beneficiary was enrolledHealth Employee EE/Spouse EE/Child(ren) Family DentalDental Employee EE/Spouse EE/Child(ren) Family VisionVision Employee EE/Spouse EE/Child(ren) Family Hidden16. Does your company offer an FSA? No Yes If (answered "yes", please provide information below)Last payroll deduction amount (medical FSA)Last payroll deduction amount (dependent care FSA)Last payroll deduction date MM slash DD slash YYYY Annual allocation Current plan year claims approved 17. Has the continuant been approved for an additional 11-month disability extension? No Yes 18. At the time of the separation or reduction in hours was the employee eligible to receive Social Security income? No Yes 19.*Company Authorize SignaturePhoneDate Please check the box below to proceed. Δ
