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Employer COBRA Renewal Form

Please supply information about your company and it's employee healthcare coverages.

Application for Renewal Only

For initial applications, please email tparr@cobra-admin.com.

 

Your Company Information

Company Legal Name
Company Address 
Phone
Fax
Contact Person Name
Contact Email

Total Number of Employees Enrolled in all Products Subject to COBRA:
                          (what's this?)

Please note that CAHS processes ONLY COBRA reinstatements and COBRA cancellations.

The Employer is responsible for processing new enrollments and the initial termination with the insurance carriers. 

What state is your group medical plans written out of?   

If your plans are age rated:

Increases due to birthdays, resulting in rate change, occur:           

Rate Grid(s) - Please upload up to three files (Types accepted: pdf, xls, xlsx, doc, docx, txt, csv, jpg, png):



 

Broker Information (if applicable)

Insurance Broker Name
Insurance Broker Email Address
Insurance Broker Phone Number

First Medical Carrier and Plan

Name
Group Number
Renewal Date
Rates Offered
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations

Second Medical Carrier and Plan

Name
Group Number
Renewal Date
Rates Offered
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations

Third Medical Carrier and Plan

Name
Group Number
Renewal Date
Rates Offered
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations

First Dental Carrier and Plan

Name
Group Number
Renewal Date
Rates Offered
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations

Second Dental Carrier and Plan

Name
Group Number
Renewal Date
Rates Offered
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations

Third Dental Carrier and Plan

Name
Group Number
Renewal Date
Rates Offered
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations

First Vision Carrier and Plan

Name
Group Number
Renewal Date
Rates Offered
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations

Second Vision Carrier and Plan

Name
Group Number
Renewal Date
Rates Offered
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations
FSA Plan Year
Vendor/Contact
 
HRA Plan Year  
Vendor/Contact  
Is the premium included in the medical premiums provided?    
HRA Category Details
Category Amount Funded Number Enrolled
Single
Two Party
Family
Total utilization for previous plan year, if not the first year:
Effective Date
for Terminations

COMMENTS

Please provide any additional comments you may feel are relevant to your application.