Form Instructions
Notice of Early Termination (Sample 7A)
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.
Before using this sample document, you should review and revise it to ensure
consistency with your plan’s procedures.
The Department of Labor mandate:
Employers/plan administrators must notify qualified beneficiaries receiving COBRA
continuation coverage of termination earlier than the applicable maximum coverage
period, such as when an employer ends group health coverage for all its employees
or when the required premium is not paid in a timely manner. The notice of early
termination must be provided as soon as possible after the termination decision
has been made.
Instructions for Notice of Early Termination of COBRA Continuation Coverage
- Enter the name and address of the employee, spouse or dependent.
- Enter the name of the group health plan.
- Enter the last day of coverage.
- Enter the names of the qualified beneficiary(ies) who are losing coverage.
- Check the applicable reason(s). If none apply, go to instruction #6 below.
- Enter a description of cause for termination of COBRA coverage.
- Enter the name of a contact person.
- Enter plan contact information as indicated.