CONTACT US
401.921.3514

Qualifying Event Notice

Fields marked with an asterisk (*) are required.

COMPANY INFORMATION

Company:*
Group Administrator Name:*
Group Administrator Email:*

EMPLOYEE INFORMATION

First Name:*
Last Name:*
Date of Birth:* (MM/DD/YYYY)
Date of Hire:*
Date Coverage Began:*
Last Day Worked:
Last Day of Coverage:
Address 1:*
Address 2:
City:*
State:*
     Zip:*
    
Employee Email:
Home Phone:
Social Security:*
- -
Gender:*
Male   Female
 

SPOUSE

First Name:
Last Name:
Social Security No:
Date of Birth:
Date Coverage Began:

DEPENDENT #1

First Name:
Last Name:
Social Security No:
Date of Birth:
Date Coverage Began:

DEPENDENT #2

First Name:
Last Name:
Social Security No:
Date of Birth:
Date Coverage Began:

DEPENDENT #3

First Name:
Last Name:
Social Security No:
Date of Birth:
Date Coverage Began:

QUALIFYING EVENT*

Check only one.

> Termination of Employment
 
 
Voluntary Removal of Dependent
Is There Severance?   Yes     No

Please note that our office must receive a completed election form before we can reinstate coverage.
 

Check all plan(s) to be paid during severance.
Enter the monthly dollar amount the former employee must pay next to each plan.

 

Start date of severance:
End date of severance:
    Plan Employee monthly payment
amount

 

Upload supporting documents, if necessary

You may optionally upload up to three files (Types accepted: pdf, xls, xlsx, doc, docx, txt, csv, jpg, png):

Document 1:

Document 2:

Document 3:

TYPE OF COVERAGE*

Check all that apply. PLEASE BE SURE TO LIST THE PLAN NAME IF YOU OFFER MORE THAN ONE PLAN.

HEALTH COVERAGE


Health Plan Provider AND PLAN NAME:


Health Plan Type:
Individual Plan
Employee/Spouse
Employee/Children
Family

DENTAL COVERAGE


Dental Plan Provider AND PLAN NAME:


Dental Plan Type:
Individual Plan
Employee/Spouse
Employee/Children
Family

VISION COVERAGE


Vision Plan Provider AND PLAN NAME:


Vision Plan Type:
Individual Plan
Employee/Spouse
Employee/Children
Family

HRA COVERAGE


HRA Plan Provider:


HRA Plan Type:
Individual Plan
Employee/Spouse
Employee/Children
Family

FLEXIBLE SPENDING ACCOUNT: For terminations, if the former employee has overspent their FSA contributions, please leave this area blank.  If they have not overspent their FSA, CAHS needs to offer the opportunity to continue under COBRA and this area must be completed. 


Flex Plan Provider:

Monthly Contribution Amount:
$
Annual Amount Funded:
$

COMMENTS

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