"Notice to Third-Party Administrator of Cobra Qualifying Event" - Montana

Notice to Third-Party Administrator of Cobra Qualifying Event is a legal document that was released by the Montana Department of Administration - a government authority operating within Montana.

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Notice to Third-party Administrator of
COBRA Qualifying Event
SECTION 1: EMPLOYER INFORMATION
Please print clearly.
Employer Name:
Date:
SECTION 2. EMPLOYEE INFORMATION
Employee Name:
Employee SSN:
Employee Address:
Street Address
City
State
Zip
SECTION 3. QUALIFYING COBRA EVENT
o Voluntary Termination of Employment
Date of Termination:
o Involuntary Termination of Employment
(other than gross misconduct)
o Reduction of Hours Worked
o Death of Employee
If the Employee is married and/or has dependent children, please provide their first and last names and dates of birth below. If you
need additional room, please attach a separate piece of paper.
Spouse Name:
DOB:
Dependent Name:
DOB:
Dependent Name:
DOB:
Dependent Name:
DOB:
Dependent Name:
DOB:
Please mail completed form to:
Montana HRA Third-party Administrator
REHN & ASSOCIATES
P.O. Box 5433
Spokane, WA 99205-0433
(509) 534-0600 or 1-800-VEBA101 (832-2101)
(509) 535-7883 Fax
montana@rehnonline.com
www.montana.rehnonline.com
Notice to Third-party Administrator of
COBRA Qualifying Event
SECTION 1: EMPLOYER INFORMATION
Please print clearly.
Employer Name:
Date:
SECTION 2. EMPLOYEE INFORMATION
Employee Name:
Employee SSN:
Employee Address:
Street Address
City
State
Zip
SECTION 3. QUALIFYING COBRA EVENT
o Voluntary Termination of Employment
Date of Termination:
o Involuntary Termination of Employment
(other than gross misconduct)
o Reduction of Hours Worked
o Death of Employee
If the Employee is married and/or has dependent children, please provide their first and last names and dates of birth below. If you
need additional room, please attach a separate piece of paper.
Spouse Name:
DOB:
Dependent Name:
DOB:
Dependent Name:
DOB:
Dependent Name:
DOB:
Dependent Name:
DOB:
Please mail completed form to:
Montana HRA Third-party Administrator
REHN & ASSOCIATES
P.O. Box 5433
Spokane, WA 99205-0433
(509) 534-0600 or 1-800-VEBA101 (832-2101)
(509) 535-7883 Fax
montana@rehnonline.com
www.montana.rehnonline.com