COBRA Election Letter
Letter electing COBRA continuation coverage after a qualifying event - job loss, hour reduction, or other.
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Jordan Alex Taylor
482 Elm Street, Apt 3B, Portland, OR 97214
Phone: +1 503 555 0118
Email: jordan.taylor@example.com
SSN (last 4): XXX-XX-1289
Date: June 19, 2026
To: Acme Corporation - HR (PEO: TriNet handles COBRA admin)
TriNet COBRA Administration, P.O. Box 4488, Reno, NV 89510
Re: COBRA ELECTION
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To the Plan Administrator,
This letter is formal election of COBRA continuation coverage under the federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA, 29 U.S.C. §1161 et seq.), or under any applicable state mini-COBRA law.
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QUALIFYING EVENT
► Voluntary termination of employment
Qualifying event date: April 30, 2026
Requested coverage start date: May 1, 2026
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QUALIFIED BENEFICIARIES ELECTING COBRA
Jordan Alex Taylor (covered employee, primary)
Spouse Aleksandra Petrova (covered as spouse, electing)
Child Ellis Taylor (covered as dependent under 26, electing)
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PLANS ELECTED
Health insurance: BlueCross BlueShield Oregon PPO Plan (employer-sponsored).
Dental insurance: Delta Dental Premier Plan.
Vision insurance: VSP Choice Plan.
(Each plan elected separately; can elect health-only without dental/vision if cost-prohibitive.)
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PAYMENT METHOD
► Direct payment by check (monthly invoices)
Estimated total monthly premium: $1,840.00
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ELECTION ACKNOWLEDGEMENTS
I understand that:
(1) I have 60 days from the later of (a) the qualifying event or (b) receipt of the COBRA election notice to elect coverage. This election is timely.
(2) The premium for COBRA coverage is up to 102% of the active-employee plan cost (100% premium + 2% admin fee), or 150% during the disability extension period.
(3) The first premium is due within 45 days of the election date; subsequent monthly premiums have a 30-day grace period from the due date.
(4) The standard COBRA period is 18 months. Specific qualifying events extend to 36 months (divorce, death, dependent age-out). Disability extension can extend the 18-month period to 29 months.
(5) Coverage is RETROACTIVE to the qualifying event date - claims incurred between the qualifying event and the election are covered if the election and first payment are timely.
(6) COBRA coverage terminates if I fail to make timely premium payments, become entitled to Medicare, become covered under another group health plan, or other terminating events.
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REQUESTED ACTION
(1) Confirm receipt of this election in writing within 14 days.
(2) Provide the first invoice / payment instructions.
(3) Confirm coverage continuation with each insurance carrier (medical, dental, vision).
(4) Issue updated insurance ID cards if applicable.
Sincerely,
_______________________________ Date: June 19, 2026
Jordan Alex Taylor
About this template
COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) requires employers with 20+ employees to offer continuation of group health-insurance coverage to qualified beneficiaries after specific qualifying events - voluntary or involuntary termination (other than gross misconduct), reduction in hours, divorce, death of covered employee, dependent age-out, and Medicare entitlement of covered employee. The COBRA period is 18 months for termination/hours-reduction events, extending to 36 months for divorce/death/age-out events; disability extension extends to 29 months. The qualified beneficiary has 60 days from the later of the qualifying event or receipt of the COBRA election notice to elect; the first premium is due within 45 days of election; subsequent premiums have a 30-day grace period. Critically, COBRA coverage is RETROACTIVE - if you elect within the 60-day window and pay timely, coverage retroactively covers any claims from the qualifying event date forward. This means many people wait until they actually need care before electing - a calculated risk that works for healthy people but costs the entire elapsed-time premium when they elect. The premium is up to 102% of the active-employee plan cost (the employee's share + the employer's share + 2% admin fee), or 150% during disability extension. State "mini-COBRA" laws extend similar coverage to employees of smaller employers (under 20 employees) - California Cal-COBRA, Connecticut, New York, Massachusetts, and others. After COBRA, individual coverage through the ACA Marketplace (healthcare.gov or state exchange) is the typical next step. Special enrolment periods (SEPs) for ACA coverage triggered by loss of employer coverage allow enrolment outside the annual open-enrolment window.
When to use it
- Voluntary termination of employment.
- Involuntary termination (not gross misconduct).
- Reduction in hours below full-time threshold.
- Divorce or legal separation from covered employee.
- Death of covered employee.
- Dependent child age-out (turning 26).
What to include
- Elector identification.
- Plan administrator information.
- Qualifying event type and date.
- Coverage start date requested.
- Qualified beneficiaries electing.
- Plans elected (medical, dental, vision separately).
- Payment method.
- Election acknowledgements.