COBRA Administrative forms
Downloadable PDFs

1. COBRA administration form
New groups fill out this form when they contract with BASIC.
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2. Insurance company information form
New groups fill out this for when they contract with BASIC.
Existing groups fill out this form when there are rate changes.
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3. Current COBRA participant information form
New groups with existing COBRA participants fill out this form.
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4. Initial notification form
Use this form for all new additions to health plan.
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5. COBRA qualifying event form
Use this form for all qualifying events
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6. Unavailable of COBRA coverage form
Please contact our COBRA department before using this form.
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