COBRA Clear for employers & brokers

Generate a sample COBRA General Notice

Built on the Department of Labor model General Notice (sometimes called the Initial Notice). Required to go to every covered employee and spouse within 90 days of becoming covered. Enter the plan and recipient information below. We handle the formatting. Always confirm the current DOL model before sending.

Employer toolkit

Five free resources for running COBRA in-house. Built on federal regulations. Nothing you enter is stored.

Generator Election Notice generator For after a qualifying event. Walks the deadlines and the formatting. Open → Generator General Notice generator For new enrollees. Sometimes called the Initial Notice. You are here Reference Sample notices reference Six sample notices for the rest of the COBRA cycle, with citations. Open → Download Excel tracker Six-tab workbook for elections, payments, and deadlines. .xlsx ↓ Download Employer reference guide Plain-English explainer of every COBRA rule employers run into. .pdf ↓

1 Plan

2 Administrator

3 Recipient

4 Review

Plan information

Plan name*

The exact name of the group health plan, as it appears in the Summary Plan Description.

Does the Plan provide retiree health coverage?*

No Most active employer plans. The bankruptcy bullet is omitted from the notice.

Yes Plan covers retirees as well. The notice includes a bullet about employer bankruptcy as a qualifying event.

Are qualified beneficiaries required to pay for COBRA continuation coverage?*

Yes, qualified beneficiaries must pay Standard for almost every plan. Notice will say "must pay for COBRA continuation coverage."

No, the Plan covers it Rare. Notice will say "aren't required to pay for COBRA continuation coverage."

Plan administrator

This is the contact information that appears at the bottom of the notice. The recipient uses this information to ask questions and send required notices (for example, divorce or a child losing dependent status).

Plan administrator name or position*

A specific person, a job title, or a department name all work.

Address line 1*

Address line 2

City*

State*

ZIP*

Phone*

Recipient-initiated notice procedures

For events the Plan does not learn about automatically (divorce, legal separation, a dependent child losing eligibility), the recipient must notify the Plan. Set the notice window and procedures here.

Notice period (days)*

Federal default is 60 days. The Plan can allow a longer period.

Additional notice procedures

Optional. Anything required by the Plan beyond the standard notice.

Notice recipient

The General Notice is required to be furnished to each covered employee and to each spouse who becomes covered, within 90 days after coverage begins. One notice addressed jointly to the employee and spouse is acceptable if both reside at the same address.

Employee first name*

Employee last name*

Spouse name (if covered and at same address)

If included, the notice will be addressed to both. If the spouse is at a different address, generate a separate notice.

Recipient address

Address line 1*

Address line 2

City*

State*

ZIP*

Dates

Coverage start date*

The date the employee or spouse first became covered under the Plan. The notice must be sent within 90 days of this date.

Notice date*

Defaults to today. The date this notice is being sent.

Review the notice

Sample only. Wording adapted from the DOL Model General Notice. Confirm the current model on the DOL website at dol.gov/agencies/ebsa/laws-and-regulations/laws/cobra before sending. Yellow highlights show your merge-in fields.