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
Employee’s 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 Employee’s 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 Participant’s 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: