COBRA Clear for employers & brokers

Generate a sample COBRA election notice

Built on the Department of Labor model election notice. Enter the plan and qualified beneficiary information below. We handle the deadline math and 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. You are here Generator General Notice generator For new enrollees. Sometimes called the Initial Notice. Open → 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 Employer

2 Plans & rates

3 Qualified beneficiary

4 Review

5 Deliver

Employer information

Employer (plan sponsor) name*

Plan administrator name*

Administrator phone*

Administrator email

Used on the notice as a contact for questions from the QB.

Administrator mailing address*

One thing to know about COBRA rate entry

Under COBRA, the QB continues the exact coverage they had at termination. They cannot switch to a cheaper plan the employer offers. Only enter the plan(s) and tier the QB was actually enrolled in. If the QB was enrolled in medical + dental but not vision, skip the vision section.

Add 2% COBRA administrative fee automatically

Under federal COBRA, the maximum premium is 102% of the total plan cost. Leave this checked and we'll apply the 2% surcharge to every rate you enter across all coverages. Uncheck only if the rates you're entering already include the 2%.

What rate should I enter? Enter the 100% plan cost, the full amount the carrier bills the employer (employer share + employee share combined). This is typically shown on your monthly invoice from the insurance carrier or TPA. Do not enter only the employee's payroll deduction. With the box above checked, we'll add the 2% administrative fee when generating the notice.

Which coverages did the QB have?

COBRA applies separately to each type of group health coverage. The QB can elect any, all, or none. Check the coverages they were enrolled in at the time of the qualifying event.

Medical

Group health plan covering hospital, physician, prescription drug, and preventive care.

Dental

Separate dental benefit plan.

Vision

Separate vision benefit plan.

Medical

Medical plan name*

Medical carrier

Tier structure*

Dental

Dental plan name*

Dental carrier

Tier structure*

Vision

Vision plan name*

Vision carrier

Tier structure*

Add a coverage

Qualified beneficiary

The person who lost coverage and is entitled to COBRA. All covered family members at this address will be addressed on the notice.

First name*

Last name*

Date of birth*

Last 4 of SSN

Used for identification only. Never full SSN. Only last 4 appears on the notice.

Phone

Helpful for TPA follow-up if the QB doesn't return the election form.

Optional. Appears on the election form for the QB's records.

Mailing address*

Required regardless of delivery method. Appears on the election notice.

Other family members covered

Each covered dependent has independent COBRA election rights. Add everyone who was on any covered plan at the time of the qualifying event. You can specify which big-3 coverages (medical, dental, vision) each person was enrolled in.

What tier is this QB on?

The tier at the time of the qualifying event. This is the tier that applies for COBRA continuation. The QB cannot change tiers outside of open enrollment unless a HIPAA special enrollment event occurs.

Qualifying event

Type of qualifying event*

Qualifying event date*

Coverage end date*

Usually last day of the month in which the event occurred.

Notice date (today or when mailed)*

The date you're sending this notice. Drives the election deadline calculation.

Review your notice

This is what will be generated. The yellow-highlighted sections are your inputs. Everything else is wording adapted from the DOL Model Election Notice. Confirm the current model on the DOL website before sending.

How do you want to deliver the notice?

Download the PDF first. From there, mail it (the safest path), or email it from your own email client. We've ordered them by legal safety.

If you're considering emailing this notice yourself: ERISA electronic disclosure rules

COBRA Clear does not email this notice to the participant. If you want to email it, you'll attach the PDF you downloaded above to your own email client and send it from there. Before you do, this is what the rules say.

Under the Department of Labor's electronic disclosure safe harbor, an employer can only email a COBRA notice to a participant who has previously signed a written consent agreeing to receive ERISA notices electronically. That consent has to document the participant's ability to access electronic notices and their agreement to receive notices this way. Without it, an emailed notice may not count as legally delivered, which can invalidate the 60-day election clock and expose the plan to claims.

Two situations where email is generally acceptable:

Active employees with work email access integral to their job duties. The DOL provides an automatic pathway for this group, but it usually does not apply to QBs who have separated from employment.
Former employees or dependents who have signed affirmative consent on file. Check your HR records before emailing. If you don't have a signed consent, email alone is not legally sufficient.

Additional nuance: if the QB has family coverage (employee + spouse, employee + child, or full family) and you only email the former employee, courts have not provided clear guidance on whether that satisfies notice to the dependent qualified beneficiaries. This is part of why mailing remains the safest path for any family-tier coverage.

Our recommendation: if you have valid electronic consent on file, email in addition to mailing, not instead of. Mailing is what protects the employer if delivery is ever disputed.

Print and mail services

These services let you upload a PDF, enter the QB's address, and they handle printing, folding, stuffing, and mailing. Per-piece pricing, no subscription, no minimums. Download your PDF above, then click through to whichever service fits.

LetterStream HIPAA certified

First-class or Certified Mail. 2-business-day mailout guarantee. Address extraction from PDFs. The only major service that explicitly maintains HIPAA certification across staff.

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DocuSend

Simple PDF upload, 2-business-day mailout, small-business friendly. Handles one-off mailings well.

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Click2Mail

USPS-partnered. No minimums, no subscription, automatic address standardization. Been around the longest.

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