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COBRA Continuation Coverage Notice
Fill out the details below to generate a COBRA general notice letter as a PDF.
Employer & Plan Information
Letter Date
Employer Name *
Employer Address
City
State
Zip
Phone
Contact Person
Plan Name
Plan Administrator Name
Plan Administrator Phone
Employee Information
Employee Full Name *
Address
City
State
Zip
Qualified Beneficiaries (dependents) - Optional
Qualifying Event
Type of Qualifying Event
Select event type
Date of Event
Coverage End Date
COBRA Coverage Costs & Deadlines
Duration (months)
Coverage Type
Select coverage
Monthly Premium ($)
Admin Fee (2%)
No Admin Fee
Total Monthly Cost
Election Deadline (60 Days from Coverage End Date)
Initial Payment Deadline
Generate & Download COBRA Letter