COBRA Second Qualifying Event Notification Form
COBRA Second Qualifying Event Notification Form
Notify the plan administrator of a second qualifying event that may extend COBRA continuation coverage from 18 to 36 months.
A second qualifying event during the initial 18-month coverage period may extend coverage to 36 months for qualified dependents. Notice must be given within 60 days.
Original qualified beneficiary name *
Your answer
Original COBRA case / member ID *
Your answer
Original qualifying event date
Affected dependent name(s)
Your answer
Relationship of affected dependents
Type of second qualifying event
Date of second qualifying event
+ 8 more questions
About this template
Notify the plan administrator of a second qualifying event that may extend COBRA continuation coverage from 18 to 36 months.
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