Please complete the following form and we will provide you with a quote for your COBRA Administration.

Client Name:
Contact Name:
Address:
City:
State:		Zip:
Telephone:
Email:
Number of Active Employees:
Benefit Eligible Employees:
Enrolled Employees for -
Medical:
Dental:
Vision:
Medical Spending:
EAP:
Enrolled COBRA Participants:
Pending COBRA Participants: (Notified but within the 60 day enrollment period)
Locations Responsible for Tracking Eligibility:
Number of Benefit Plans Subject to COBRA -
Medical:
Dental:
Vision:
Percentage of Annual Turnover		%
Who currently administers COBRA compliance?
Will eligibility data be available electronically?		Yes	No
Would administrator be responsible for reporting eligibility to carriers?		Yes	No
If yes, would carriers be required to accept electronic eligibility?		Yes	No
Would the administrator be responsible for COBRA billing reconciliation?		Yes	No
Are COBRA general notices sent to each newly enrolled employee at the home address when they first become benefit enrolled?		Yes	No
Proposed effective date:
How did you hear about us?
Comments:
Completed By:
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