COBRA Qualifying Event Notification - ?· COBRA Qualifying Event Notification Client Name _____ Client…

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    08-Oct-2018

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  • CO-3437-052813

    TASC 2302 International Lane Madison, WI 53704-3140 1-800-422-4661 Fax: 608-663-2753 www.tasconline.comThe information in this communication is confidential and may be used by the authorized

    recipient only for its intended purpose only. Any other use or disclosure is prohibited.

    COBRA Qualifying Event NotificationClient Name ________________________________________________________________ Client ID# ______________________

    Branch Name (if applicable) ______________________________________ Submitted by ___________________________________

    PERSONAL INFORMATION

    Employees Name (Last, First, MI) ______________________________________________________________ Gender m M m F

    Participant Name (If different than Employee) ______________________________________________________ Gender m M m F

    Address __________________________________________________________________________________________________ Street City State Zip

    Email Address _______________________________________________ Home Phone Number _____________________________

    DOB ____________________ SSN ____________________________ Marital Status m S m M Date of Hire ______________ (Only needed if Participant was an employee.)

    QUALIFYING EVENT INFORMATION*

    Qualifying Event (QE) Date _________________________________ COBRA Start Date __________________________________ (i.e. day after QE; first of month after QE; other)

    Select one of the following QE Types:m Involuntary termination of employment m Voluntary termination of employment m Cessation of dependent status m Reduction in hours of employment m Divorce or legal separation from employee m Start of bankruptcy proceeding by employer m Death of employee m Employees Medicare entitlement

    PRESENT PLAN BENEFITS INFORMATION**

    Original Effective Date of: Health ____________________ Dental ____________________ Vision ______________________

    Indicate the level of coverage for each Plan that the Participant was enrolled in as of the Qualifying Event date.

    Coverage Name and Option of Benefit Plan PQB PQB and PQB and PQB and PQB andType (e.g. PPO or HMO if applicable) Only Spouse 1 Child Family Children

    Health ______________________________________________ ______ _______ ________ _______ ________Dental ______________________________________________ ______ _______ ________ _______ ________Vision ______________________________________________ ______ _______ ________ _______ ________Other ______________________________________________ ______ _______ ________ _______ ________

    FSA Annual Election Amount __________________________________ Claims Paid To Date _____________________________Employee Contribution _______________________________________ FSA Plan Year End Date __________________________

    DEPENDENT INFORMATION***List the name (Last, First, MI) of all dependents covered as of the Participants Qualifying Event date.

    Spouse__________________________________ DOB___________________ SSN______________________ Gender m M m FChild__________________________________ DOB___________________ SSN______________________ Gender m M m FChild__________________________________ DOB___________________ SSN______________________ Gender m M m FChild__________________________________ DOB___________________ SSN______________________ Gender m M m FChild__________________________________ DOB___________________ SSN______________________ Gender m M m F

    SEVERANCE OPTION* If employer is subsidizing all or a portion of the COBRA premium as part of a severance agreement with the Qualified Beneficiary, complete the information below.Adjusted Dollar Amount _______________ or % Paid by Employer ________________ Severance End Date ___________________

    For TASC Office Use Only: Entered by _________________________________ Date Entered __________________________

    Please return the completed form(s) to:

    Client Name: Client ID: Branch Name if applicable: Submitted by: s Name Last First MI: Participant Name If different than Employee: Address: Email Address: Home Phone Number: DOB: SSN: Date of Hire: Qualifying Event QE Date: COBRA Start Date: Original Effective Date of Health: Dental: Vision: Health: Dental_2: Vision_2: Other: Only 1: Only 2: Only 3: Only 4: Spouse 1: Spouse 2: Spouse 3: Spouse 4: 1 Child 1: 1 Child 2: 1 Child 3: 1 Child 4: Family 1: Family 2: Family 3: Family 4: Children 1: Children 2: Children 3: Children 4: FSA Annual Election Amount: Claims Paid To Date: Employee Contribution: FSA Plan Year End Date: Spouse: DOB_2: SSN_2: Child: DOB_3: SSN_3: Child_2: DOB_4: SSN_4: Child_3: DOB_5: SSN_5: Child_4: DOB_6: SSN_6: Adjusted Dollar Amount: or Paid by Employer: Severance End Date: Entered by: Date Entered: Radio Button1: OffRadio Button2: OffRadio Button3: OffRadio Button4: OffRadio Button5: OffRadio Button6: OffRadio Button7: OffRadio Button9: OffRadio Button10: Off

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