Forms & Checklists: Benefits

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Each of the more than 350 HR forms and documents included in this employment law and business law resource center is listed with a description of the form and how it should be used. Most descriptions of these forms also include details as to whether additional documents are needed to complete a specific HR process.

Navigate these HR forms and checklists through topics and subtopics, and click View. Or, simply glance through the alphabetical list and click on a form title.

  • Acknowledgment of Receipt of Notification of COBRA Rights

    Provide this form to an employee if the employee has coverage for himself/herself plus any other family members and coverage is being ended due to termination of employment or reduction in hours. You need to send out additional COBRA notices to those individuals indicated on the form who do not reside with the employee.

  • Cal-COBRA - Notice to Carrier

    Send this notice to the health/disability insurance carrier when any qualified beneficiary becomes subject to Cal-COBRA because of a qualifying event. You must notify the employee’s carrier within 31 days of the event.

  • Cal-COBRA - Notice to Employee

    Send this notice to an employee at least 30 days before a current group benefit plan terminates because of a change in group plans. You must send information about the new group benefit plan, benefits information, premium information, enrollment forms, instructions, etc., necessary to allow the qualified beneficiary (employee) to continue coverage. Send this notice via certified mail and keep a record of the mailing on file.

  • Certificate of Group Health Plan Coverage

    Give this form to employees and any dependents covered by the company’s group health plan as of the COBRA qualifying event. Complete each of the 11 sections before sending and retain a copy with a copy of the COBRA Notice. The employee may need to provide this document to certify any medical advice, diagnosis, care or treatment that was recommended or received for a condition within six months prior to enrollment in a new plan.

  • CHIPRA Fact Sheet

    The DOL has posted a model Employer children's health insurance program (CHIP) Notice that can be used to satisfy the employer notice requirement under the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA). CHIPRA added new notice and disclosure obligations for employers that provide group health plans in states that offer Medicaid or state CHIP assistance in the form of premium assistance subsidies.  CHIPRA also created additional HIPAA special enrollment rights that permit eligible employees and their dependents to enroll in an employer's group health plan in two situations: (1) when Medicaid or CHIP coverage is terminated due to loss of eligibility; and (2) upon eligibility for a premium assistance subsidy under Medicaid or CHIP. The Employer CHIP Notice must be provided annually, on an automatic basis and free of charge. It must inform each employee (regardless of enrollment status) of potential opportunities for premium assistance in the state in which the employee resides.

    • Download (PDF, 22K)
    • Updated: 3/23/2010
  • COBRA Administration Guide

    Begin using this COBRA administration guide when an employee is hired and refer back to it when a qualifying event occurs. Doing so ensures you use the proper, required forms relating to COBRA (20 or more employees) and Cal-COBRA (2 to 19 employees), as applicable.

    • Download (PDF, 160K)
    • Updated: 8/19/2008
  • COBRA Continuation Coverage Election Notice - California Employees

    Modify this form according to the coverage plans that you offer and send it out with all COBRA notices. The employee is required to fill out and return the form to the plan administrator within 60 days of a qualifying event or the date he/she was notified of COBRA continuation rights.

  • COBRA Continuation Coverage Election Notice - Outside California

    Modify this form according to the coverage plans that you offer and send it out with all COBRA notices. The employee is required to fill out and return the form to the plan administrator within 60 days of a qualifying event or the date he/she was notified of COBRA continuation rights.

  • COBRA Flyer for Employees

    Informational flyer for employees about the COBRA premium reduction extension.

    • Download (PDF, 229K)
    • Updated: 4/30/2010
  • COBRA Flyer for Employees - Spanish

    Informational flyer for employees about the COBRA premium reduction extension.

    • Download (PDF, 210K)
    • Updated: 4/30/2010
  • COBRA Flyer for Employees on Application for Review

    Informational flyer for employees whose request for a COBRA Premium Reduction was denied, includes information about how to request an expedited review.

    • Download (PDF, 288K)
    • Updated: 4/30/2010
  • COBRA Flyer for Employees on Application for Review - Spanish

    Informational flyer for employees whose request for a COBRA Premium Reduction was denied, includes information about how to request an expedited review.

    • Download (PDF, 341K)
    • Updated: 4/30/2010
  • COBRA Flyer for Employers

    Informational flyer for employers about the COBRA premium reduction extension and where to get more information.

    • Download (PDF, 186K)
    • Updated: 2/5/2010
  • COBRA Notice to Plan Administrator

    Use this form to provide notice to the plan administrator within 30 days of an employee's loss of coverage due to termination, reduction in hours, death, or employer bankruptcy.

    • Download (PDF, 115K)
    • Updated: 10/7/2008
  • COBRA Poster

    Poster for employees that includes information on how to protect their health coverage when they lose their jobs.

    • Download (PDF, 176K)
    • Updated: 4/30/2010
  • COBRA Poster - Spanish

    Poster for employees that includes information on how to protect their health coverage when they lose their jobs.

    • Download (PDF, 172K)
    • Updated: 4/30/2010
  • COBRA Premium Reduction Fact Sheet

    Basic Fact Sheet published January 27, 2010 that includes information about the extension and notice requirements.

    • Download (PDF, 71K)
    • Updated: 4/30/2010
  • COBRA Premium Reduction Fact Sheet - Spanish

    Basic Fact Sheet published January 27, 2010 that includes information about the extension and notice requirements.

    • Download (PDF, 51K)
    • Updated: 4/30/2010
  • COBRA Subsidy Documentation Checklist

    Use this form between September 1, 2008 and December 31,2009 to document information relating to employees receiving the COBRA subsidy. 

  • COBRA Subsidy Extension - Model Notice of Extended Election Period CEA

    Plans that are subject to continuation coverage provisions under Federal or State law must provide, before the end of the required time period for providing a COBRA election notice, the Notice of Extended Election Period to all individuals who:

     experienced a qualifying event that was a termination of employment at some time on or after April 1, 2010 and by May 31, 2010;

    were provided notice that did not inform them of their rights under ARRA, as amended by CEA;

    and either chose not to elect COBRA continuation coverage at that time or elected COBRA but subsequently discontinued that coverage.

    • Download (DOC, 190K)
    • Updated: 5/4/2010
  • COBRA Subsidy Extension - Model Notice of New Election Period CEA

    Plans subject to continuation coverage provisions under Federal or State law should provide, within 60 days of the date of the termination of employment, a Notice of New Election Period to all individuals who:

    experienced a qualifying event that was a reduction in hours at any time from September 1, 2008 through May 31, 2010;

    subsequently experience a termination of employment at any point from March 2, 2010 through May 31, 2010;

    and either did not elect continuation coverage when it was first offered or elected but subsequently discontinued the coverage.

    Generally, individuals who have experienced a qualifying event that consists of a reduction of hours and who, from March 2, 2010 through May 31, 2010, experience an involuntary termination of employment must be provided this notice within 60 days of the event. Additionally, CEA provides that for the April 1, 2010 through April 14, 2010 period, the notice requirement attaches to any termination of employment. The Department strongly recommends that notice be provided to individuals who experienced any termination of employment because employers may be subject to civil penalties if it is later determined that the termination was involuntary and notice was not provided.

    • Download (DOC, 185K)
    • Updated: 4/30/2010
  • COBRA Subsidy Extension - Model Supplemental Information Notice CEA

    Plans that are subject to continuation coverage provisions under Federal or State law should provide the Supplemental Information Notice to all individuals who elected and maintained continuation coverage based on the following qualifying events:

    all qualifying events related to a termination of employment that occurred from March 1, 2010 through April 14, 2010 for which notice of the availability of the premium reduction available under ARRA was not given;

    or reductions of hours that occurred during the period from September 1, 2008 through May 31, 2010 which were followed by a termination of the employee’s employment that occurred on or after March 2, 2010 and by May 31, 2010.

    For the first item above, plans must provide this notice to all individuals with a qualifying event related to any termination of employment if they have not already been provided notice of their rights under ARRA. This notice must be provided before the end of the required time period for providing a COBRA election notice. For the second item above, generally, individuals who experience an involuntary termination of employment from March 2, 2010 through May 31, 2010 after experiencing a qualifying event that consists of a reduction of hours must be provided this notice within 60 days of the termination of employment. However, as noted above, CEA requires plans to provide notices to all individuals with qualifying events related to any termination of employment that occurred from April 1, 2010 through April 14, 2010. In those cases, this notice must be provided before the end of the required time period for providing a COBRA election notice. Because employers may be subject to civil penalties if it is later determined that the termination was involuntary, the Department strongly recommends that notice be provided to individuals who experienced any termination of employment.

    • Download (DOC, 172K)
    • Updated: 4/30/2010
  • COBRA Subsidy Extension - Model Updated General Notice CEA

    Plans subject to the Federal COBRA provisions must provide the updated General Notice to all qualified beneficiaries (not just covered employees) who experienced a qualifying event at any time from September 1, 2008 through May 31, 2010, regardless of the type of qualifying event, and who have not yet been provided an election notice. This model notice includes updated information on the premium reduction, as well as information required in a COBRA election notice.

    Note: Individuals who experienced a qualifying event that was a termination of employment from April 1, 2010 through April 14, 2010 may not have been provided proper notice. Those individuals who have not been provided any notice must get the updated General Notice and receive the full 60 days from the date the updated notice is provided to make a COBRA election. Those individuals who have been provided a notice that did not include information related to the most recent extension must also be provided this updated information. Depending on the specific circumstances, either the Supplemental Information Notice or the Notice of Extended Election Period may be used. See below for additional details.

    • Download (DOC, 184K)
    • Updated: 5/19/2010
  • COBRA Subsidy Extension for Cal-COBRA - Model Updated Alternative Notice CEA

    Insurance issuers that offer group health insurance coverage that is subject to comparable continuation coverage requirements imposed by State law must provide the Alternative Notice to all qualified beneficiaries, not just covered employees, who have experienced a qualifying event through May 31, 2010. However, because continuation coverage requirements vary among States, this notice should be further modified to reflect the requirements of the applicable State law. Issuers of group health insurance coverage subject to this notice requirement should feel free to use the model Alternative Notice, the model Notice of New Election Period, the model Supplemental Information Notice, the model Notice of Extended Election Period, or the model General Notice (as appropriate).

    • Download (DOC, 137K)
    • Updated: 5/19/2010
  • General Notice of COBRA Continuation Coverage Rights - California Employees

    Provide this form to an employee or spouse within 90 days of the commencement of coverage or the first date at which the plan administrator is required to advise a qualified beneficiary of the right to elect coverage.

    • Download (PDF, 177K)
    • Updated: 3/23/2009
  • General Notice of COBRA Continuation Coverage Rights - Outside California

    Provide this form to an employee or spouse within 90 days of the commencement of coverage or the first date at which the plan administrator is required to advise a qualified beneficiary of the right to elect coverage. Use this form for employees outside California.

  • HIPP Notice - English

    Send this English version at the same time you send the COBRA Notice, to notify terminating employees of special state programs that provide for the state to pay the COBRA premium under certain circumstances. Be careful not to confuse HIPP, California's Health Insurance Premium Payment Program, with HIPAA.

    • Download (PDF, 30K)
    • Updated: 11/6/2009
  • HIPP Notice - Spanish

    Send this Spanish version at the same time you send the COBRA Notice, to notify Spanish-speaking terminating employees of special state programs that provide for the state to pay the COBRA premium under certain circumstances. Be careful not to confuse HIPP, California's Health Insurance Premium Payment Program, with HIPAA.

    • Download (PDF, 75K)
    • Updated: 11/6/2009

Why Use HR Forms?

Having the correct HR forms is one of the simplest ways to ensure your business is complying with state and federal law. HR forms and checklists are essential tools to keep your HR department operating efficiently and effectively. Using this forms and checklists resource center, you not only can find the paperwork you need, but you also can gain a better understanding for how to handle your business’s HR concerns.

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