Quick Check On Your Eligibility

Attention: Before you get started, do a quick check on your eligibility for the COBRA premium reduction.

If -

• you were covered by the employer’s group health plan on the last day of the employee's employment*;

• there is an ongoing health plan responsible for providing COBRA continuation coverage;

• the employee's job termination was involuntary** and occurred during the period beginning September 1, 2008 through December 31, 2009; and

• you are eligible for COBRA at any time during that period due to the employee’s job loss and not divorce, legal separation, entitlement to Medicare, loss of dependent status, or death of the covered employee.

then you may be eligible for the COBRA premium reduction.

If you have questions on how to complete this application or about eligibility for COBRA or the COBRA premium reduction, please see our web site at www.dol.gov/COBRA. You may also call a DOL Benefits Advisor toll-free at 1.866.444.3272. If you feel that you have been inappropriately denied the COBRA premium reduction, complete the attached application.

*Note: newborns, adopted children or children placed for adoption added through special enrollment count as if they were on the plan on the last day of the employee’s employment.

**For help in determining what job loss situations are involuntary terminations, see the IRS guidance.

What You Will Need To Begin

The Department of Labor’s review cannot begin until we have a complete application, including copies of all documentation that you believe would assist the Department in making a determination regarding your application. Before you begin filling out the online application, gather any documentation that you have including copies of the documents listed below.  You will need to have each document in an electronic format (see list below), and saved on electronic media (such as your computer's hard drive, disk, or thumbdrive). Each document must accompany your application and can be attached to the application by following the instructions in the online application.

Note: If you are filing online, you cannot save your information. Once you have begun filling out the application, if left unattended, you will receive a 15 minute warning and your computer session will time-out after 30 minutes.

These documents will assist you in completing your application

• COBRA election notice;

• Information on your plan sponsor, employer, insurance company, and/or plan administrator;

• A "Request for Treatment as an Assistance Eligible Individual" or other form used to request the premium reduction;

• Insurance information card;

• Payroll stubs showing deductions for health benefits;

• Any documents detailing the date and circumstances of the termination of the employee’s employment; or

• Any documentation you were provided regarding the denial of the premium reduction.

Acceptable Electronic File Formats

• Plain text (txt or rtf)

• MS Word^® (doc)

• MS Excel^® (xls)

• Joint Photographic Experts Group (jpeg)

• CompuServe Graphics Interchange (gif)

• Tagged Image File (tiff)

• Bitmap (bmp)

• Adobe Portable Document Format (pdf)