Form Instructions
COBRA Continuation Coverage Election Notice (Sample 3A)
The Consolidated Omnibus Budget Reconciliation Act of 1985 is a federal law. COBRA
allows employees losing employer health plan coverage to continue receiving it through
the employer, but at their own expense, generally for up to 18 months.
As a reminder, HMSA is not the employer/plan administrator (plan administrators
are typically the employer) and therefore does not distribute COBRA notices required
to be furnished by employers/plan administrators. Upon request, however, we can
assist with monthly billings, dues collection, and tracking COBRA coverage periods.
In addition, please note that the form is for use by single-employer group health plans.
Election Notice
An election notice must be provided when a covered employee has a qualifying event
(i.e., termination of employment, reduction of hours, divorce, etc.). The
Election Form and the document entitled Important Information About
COBRA Continuation Coverage Rights document (3C) must also be provided
with this Election Notice. Before using the sample Election Notice and Election
Form, please review and revise them to ensure they are consistent with your plan’s
procedures.
Plan administrators must furnish qualified beneficiaries with an election notice
no later than 14 days after receiving notice from the employer, employee, or spouse,
that a qualifying event has occurred. If the employer and the plan administrator
are one and the same, notice must be provided within 44 days from the date of the
qualifying event or from the date coverage ends.
Instructions for COBRA Continuation Coverage Election Notice
- Enter the date of the Election Notice.
- Enter the name of the group health plan.
- Enter the name of the employer/plan administrator.
- Identify the qualified beneficiary(ies) by name or status.
- Enter the date coverage will end.
- Check the applicable qualifying event.
- Enter either 18 or 36 depending on the qualifying event.
- Check the applicable qualified beneficiary category. You may add the name(s) of
the qualified beneficiary(ies) next to the appropriate category.
- Enter the start date for COBRA coverage.
- Enter the end date for COBRA coverage based on the length of coverage applicable
for the qualifying event.
- Enter the date the current COBRA premium will end.
- Enter the applicable dues that will be required for each option per month of coverage.
Please contact your HMSA Account Management & Sales representative for cost information.
- Enter the plan contact information as indicated.