SMACC COBRA QUALIFYING EVENT NOTIFICATION FORM

Employer Name:______________________________________________________________________________
Employee Name:______________________________________________________________________________
Employee Address:____________________________________________________________________________
City: ____________________________________State: ____________________________Zip:_______________
Employee Social Security #: ______-________-_________ Employee Date of Birth:_________________________
Date of Hire: ________________ Benefit Begin Date: _____________ Qualifying Event Date: _________________

QUALIFYING EVENT: (PLEASE CHECK ONE)
Termination of a covered employee’s employment (other than gross misconduct) Please indicate below whether
termination was voluntary or involuntary.
_____ Voluntary _____ Involuntary

_____ A Reduction in a covered employee’s hours of employment
_____ The death of a covered employee, please list detailed information below
_____  A divorce or legal separation from the covered employee, please list detailed information below
_____ Ceasing to be a dependent child under the terms of the plan
_____ The covered employee becomes eligible for Medicare, please list date eligible

QUALIFIED BENEFICIARIES  * RELATIONSHIP TO EMPLOYEE * DATE OF BIRTH * SOCIAL SECURITY NUMBER:
________________________  __________________________   _____________    ________________________
________________________  __________________________   _____________    ________________________
________________________  __________________________   _____________    ________________________
________________________  __________________________   _____________    ________________________
________________________  __________________________   _____________    ________________________

Coverage Currently Provided to Employee and/or Qualified Beneficiaries.
(Please note total cost of monthly premiums – do not include the additional 2% in the calculation. Also please list the
detailed carrier information as outlined below.)

HEALTH INSURANCE               CARRIER NAME & PLAN NAME                MONTHLY PREMIUM
Employee Only                           __________________________                _________________
Employee + Child(ren)               __________________________                _________________         
Employee + Spouse                   __________________________                _________________     
Family                                        __________________________                _________________                

DENTAL INSURANCE                CARRIER NAME & PLAN NAME                MONTHLY PREMIUM
Employee Only                           __________________________               _________________
Employee + Child(ren)               __________________________                _________________         
Employee + Spouse                   __________________________                _________________        
Family                                        __________________________                _________________                
A Rate Grid for the Group may be attached, if applicable.

_______ Other (Please note if: FSA, HRA, Vision, EAP, Etc.):_______________________________________

I certify that the beneficiary noted above has incurred a qualifying event and is now eligible for COBRA. I have notified
the Plan Administrator (
BENEFIC) within a maximum of 14-day period in order for the Administrator to proceed with
notifying the qualified beneficiary within the required time frame.

Employer’s signature: ____________________________________________ Date: ____________________

RETURN VIA EMAIL TO: COBRA@beneficusa.com - Benefic Administrative Solutions, LLC, 222 East Witherspoon
Street, Suite 105B, Louisville, KY 40202, Phone: (502) 365-9440, Fax: (502) 638-2481.

Accepted and Completed by BENEFIC Rep: ___________________________ Date: _____________________