Get Acknowledgment of Receipt Notification of COBRA Rights

COBRA coverage lets you pay to stay on your job-based health insurance for a limited time after your job ends (usually 18 months). You usually pay the full premium yourself, plus a small administrative fee. Contact your employer to learn about your COBRA options.

Personalize. Provide this form to an employee if the employee has coverage for himself/herself plus any other family members and coverage is being ended due to termination of employment or reduction in hours.

Legally, if your employer is subject to COBRA requirements, they must notify the organization's group health plan administrator within 30 days of your last day with your employer. At that point, the plan administrator then has 14 days to notify the former employee of their COBRA rights.

Your employer has 30 days from this qualifying event to notify the COBRA administrator of your election. Keep in mind that if you wait to enroll, you won't save any money. COBRA is always retroactive to the day after your employer coverage ends. So, you'll need to pay your premiums for that period too.

Within 14 days of that notification, the plan administrator is required to notify the individual of his or her COBRA rights. If the employer also is the plan administrator and issues COBRA notices directly, the employer has the entire 44-day period in which to issue a COBRA election notice.

COBRA continuation coverage notices are documents that explain employees' rights under the Consolidated Omnibus Budget Reconciliation Act of 1985. These documents generally contain a variety of information, including the following: The name of the health insurance plan.

14-Day Notice Period The HR office must provide the COBRA Election Notice and Election Form to qualified beneficiaries within 14 days from the date of the qualifying event or loss of coverage, or when the HR office is notified, whichever comes first.

There are a few reasons you've received a Cobra Notification. Most commonly you will receive the following letters: Initial Notification: Upon enrollment into our group plan you will receive this letter. The purpose of this letter is to inform you of your rights and responsibilities as a plan participant.