COBRA Implementation Kit

COBRA Abstract

"*" indicates required fields

1Company Information

2Billing Information

3Broker/ Agent Contact(s)

4Admin Provisions

5Carrier Enrollment Contact Information

6Medical Plan

7MEC Plan

8Supplemental Health Plans

9Dental Plan

10Vision Plan

11EAP

12Medical FSA

13HRA

14Optional Services

15Form Downloads/Uploads

16Signature & Submission

BILLING INFORMATION
COBRA Admin America Administration Services Effective Date
mm/dd/yyyy
Broker Billed
Broker Billed
Broker Address
Street Address Address Line 2 City State ZIP Code

Broker Billing Contact
First Last
Contact for invoicing of administration fees
Broker Billing Email*
Enter Email Confirm Email

Employer Billing Contact Is Same As:*

Other - Complete Employer Billing Contact Information Below

Primary Employer Contact

Secondary Employer Contact
Employer Billing Contact*
First Last
Contact for the Invoicing of administration fees
Employer Billing Email*
Enter Email Confirm Email

Employer Billing Telephone
Are There Additional Employer Billing Contacts?
Additional Employer Billing Contacts
Contact Name
Contact Phone#
Contact Email

Method of Payment for Admin Fees*

ACH (AA debits the Company's bank account) - fill out the AA ACH Form for Admin Fees

Credit Card

Company initiated Payment via ACH.

Company mails check to AA each billing cycle

Other

*Admin America invoices annually. Initial invoices are billed through the end of the current plan year. Invoices are based on the enrollment at the time the invoice is issued.
ACH Form for Admin Fees
ACH Instructions for Admin Fees Payments

BROKER/AGENT INFORMATION
Agent/Broker
Agent Company*
Agency Tax ID Number*
Agent Physical Address*
Street Address Address Line 2 City State ZIP Code

Broker/Agent Name
First Last
Broker/Agent Email

Broker Account Manager*
First and Last Name
Email Address
Phone Number

GENERAL RIGHTS NOTICE INFORMATION
The Initial Notice, also known as the General Rights Notice, is a COBRA-required document that must be sent to all new plan participants and covered dependents. This notice informs them of their rights and obligations in the event of a Qualifying Event.

Failure to properly distribute this notice can result in penalties and must be self-reported on IRS Form 8928. Additionally, in cases where an individual files a lawsuit against the employer for an alleged COBRA violation, the General Notice often serves as a key legal defense.
Have all of the employees whom are benefit eligible received an Initial Notice?*
If No, Elect Fee*
A fee of $3.50 will be applied to each letter sent to a participant enrolled prior to the effective date of Admin America COBRA Services.
Consent*
I agree to the $3.50 per Initial Notice fee.
DISABILITY EXTENSION
If a COBRA participant is determined to be disabled by the Social Security Administration, they may be eligible to extend their COBRA coverage for up to 29 months. Should the participant choose to extend their COBRA beyond the regular period, employers have the option to increase the standard 2% COBRA fee to 50%. Admin America retains the 2%, and the employer receives the remaining difference.Qualifying Event.
In the event of a participant accepting the Disability Extension, what fee would the Employer want the participant to pay?
LEVEL OF SERVICE
Authorize the level of service you are electing.*
COBRA PARTICIPANT REINSTATEMENT OPTIONS:

Carrier Notification Service:
Admin America will notify the relevant insurance carriers to reinstate or enroll coverage for COBRA participants upon receipt of their COBRA Election Form and Initial Premium Payment. Additionally, Admin America will inform the appropriate insurance carriers to terminate coverage for any current COBRA participant when necessary.

Broker Notification Service:
Admin America will notify the designated broker contact regarding the need to reinstate or enroll, as well as terminate, COBRA participants. The broker will then initiate the necessary actions with the carrier(s) upon receiving this notification.

Would you like to participate in GoHealth?
Admin America has partnered with GoHealth to offer alternative individual insurance coverage options to COBRA Qualified Beneficiaries. GoHealth is a private exchange solution that provides Qualified Beneficiaries with access to online decision support tools as well as telephone guidance from licensed insurance support tools as well as telephone guidance from licensed insurance advisors. GoHealth also offers Qualified Beneficiaries information about coverage and subsidies available through the public ACA Marketplace in their state. Admin America does not want to compete with any similar efforts that your insurance agent/broker may be utilizing to offer alternative insurance coverage to your COBRA Qualified Beneficiaries. If you would prefer that Admin America NOT offer this service, please select No.
COBRA THIRD-PARTY ADMINISTRATOR TAKEOVER NOTIFICATION
Please be advised that your company has changed COBRA Third-Party Administrators (TPAs). It is important to notify your insurance carrier of this change to ensure a smooth transition and prevent any disruption in coverage or communication. Please note that some insurance carriers may require a form to be completed—be sure to check with your carrier for their specific requirements.
Consent*
Consent Acknowledgment: COBRA TPA Change:
I acknowledge that I have read and understand the notice regarding the COBRA Third-Party Administrator change. I agree to contact the applicable insurance carriers to notify them of this change and to complete any required documentation as needed.

Please provide the name of the medical insurance carrier, along with the individual or team name to whom reinstatements should be directed. *Note: This should be the enrollment department within the carrier, not the sales, implementation, or customer service contacts.
Medical
Medical Carrier Enrollment Contact Name or Team Name:
Medical Carrier Enrollment Contact Email:

Medical Carrier Enrollment Phone #
Medical Group/Contract #*
Are Domestic Partners included?*

MEC (ACA-Supplemental) Plan
MEC Carrier Enrollment Contact Name or Team Name:
MEC Carrier Enrollment Contact Email:

MEC Carrier Enrollment Phone #
MEC Group/Contract #*
Are Domestic Partners included?*

Dental Plan
Dental Carrier Enrollment Contact Name or Team Name:
Dental Carrier Enrollment Contact Email:

Dental Carrier Enrollment Phone #
Dental Group/Contract #*
Are Domestic Partners included?*

GAP (Supplemental) Plan
GAP Carrier Enrollment Contact Name or Team Name:
GAP Carrier Enrollment Contact Email:

GAP Carrier Enrollment Phone #
GAP Group/Contract #*
Are Domestic Partners included?*

Telemedicine (Supplemental) Plan
Telemedicine Carrier Enrollment Contact Name or Team Name:
Telemedicine Carrier Enrollment Contact Email:

Telemedicine Carrier Enrollment Phone #
Telemedicine Group/Contract #*
Are Domestic Partners included?*

Vision Plan
Vision Carrier Enrollment Contact Name or Team Name:
Vision Carrier Enrollment Contact Email:

Vision Carrier Enrollment Phone #
Vision Group/Contract #*
Are Domestic Partners included?*

Employee Assistance Program (EAP) Plan
EAP Carrier Enrollment Contact Name or Team Name:
EAP Carrier Enrollment Contact Email:

EAP Carrier Enrollment Phone #
EAP Group/Contract #*
Are Domestic Partners included?*

Medical FSA Plan
Medical FSA Carrier Enrollment Contact Name or Team Name:
Medical FSA Carrier Enrollment Contact Email:

Medical FSA Carrier Enrollment Phone #
Medical FSA Group/Contract #*
Are Domestic Partners included?*

MEDICAL PLAN INFORMATION
Is Medical Plan Fully Insured or Self Insured
Does Medical Carrier require monthly paid thru date reports?
Medical carrier enrollment contact*
Please provide the name of the medical insurance carrier, along with the individual or team name to whom reinstatements should be directed. *Note: This should be the enrollment department within the carrier, not the sales, implementation, or customer service contacts.
Medical carrier enrollment contact email (DO NOT enter the broker contact here)*

*It is crucial to provide accurate contact information. This should be the email address for the designated contact to whom reinstatement of coverage requests should be sent.
Coverage will end for Qualified Beneficiaries*
List Other
Start date for the current medical plan rates*
<mm/dd/yyyy
End date for the current medical plan rates*
mm/dd/yyyy
Are Domestic Partners included?*
Check To Upload Medical Age Banded Rates
Upload Age Banded Rates
1 Medical Plan*
Insurance Carrier
Medical Plan Name

1 Medical Plan
Medical Group#
Employer Division (if applicable)

1 Medical Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more
Add a second Medical Plan

No

Yes
2 Medical Plan*
Insurance Carrier
Medical Plan Name

2 Medical Plan
Medical Group#
Employer Division (if applicable)

2 Medical Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more
Add a third Medical Plan

No

Yes
3 Medical Plan*
Insurance Carrier
Medical Plan Name

3 Medical Plan
Medical Plan Name
Medical Group#
Employer Division (if applicable)

3 Medical Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more
Add a fourth Medical Plan

No

Yes
4 Medical Plan*
Insurance Carrier
Medical Plan Name

4 Medical Plan
Medical Plan Name
Medical Group#
Employer Division (if applicable)

4 Medical Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more
Add a fifth Medical Plan

No

Yes
5 Medical Plan*
Insurance Carrier
Medical Plan Name

5 Medical Plan
Medical Plan Name
Medical Group#
Employer Division (if applicable)

5 Medical Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more
Are Domestic Partners included?*

No

Yes
Upload Age Banded Medical Rate Sheet

Drop files here or

Max. file size: 256 MB, Max. files: 3.

Please provide any additional information we should be aware of below.

MEC PLAN INFORMATION
Minimum Essential Coverage (MEC) Plan is a health plan that meets the Affordable Care Act’s (ACA) basic coverage requirements by providing access to preventive and wellness services. While it satisfies the ACA’s individual and employer mandate, it does not typically include full major medical benefits.
Is MEC Plan Fully Insured or Self Insured
Does MEC Carrier require monthly paid thru date reports?
MEC carrier enrollment contact*
Please provide the name of the MEC insurance carrier, along with the individual or team name to whom reinstatements should be directed.*Note: This should be the enrollment department within the carrier, not the sales, implementation, or customer service contacts.
MEC carrier enrollment contact email (DO NOT enter the broker contact here)*

*It is crucial to provide accurate contact information. This should be the email address for the designated contact to whom reinstatement of coverage requests should be sent.
Coverage will end for Qualified Beneficiaries*
Start date for the current MEC plan rates*
mm/dd/yyyy
End date for the current MEC plan rates*
mm/dd/yyyy
Are Domestic Partners included?*
Check To Upload Dental Age Banded Rates
Upload Age Banded Rates
MEC Plan*
Insurance Carrier
MEC Plan Name

MEC Plan*
MEC Group#
Employer Division (if applicable)

MEC Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more
Is a second MEC Plan offered?

No

Yes
2nd MEC Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more
Upload Age Banded MEC Rate Sheet

Drop files here or

Max. file size: 256 MB, Max. files: 3.

Please provide any additional information we should be aware of below

Supp Health Plan carrier enrollment contact*
Please provide the name of the Supp Health Plan insurance carrier, along with the individual or team name to whom reinstatements should be directed.*Note: This should be the enrollment department within the carrier, not the sales, implementation, or customer service contacts.

Supp Health plan carrier enrollment contact email (DO NOT enter the broker contact here)*

*It is crucial to provide accurate contact information. This should be the email address for the designated contact to whom reinstatement of coverage requests should be sent.

Paid thru date reports required?
Does the Health Plan carrier require monthly paid thru date reports?

Coverage will end for Qualified Beneficiaries*

Start date for the current Sup Health plan rates*
mm/dd/yyyy
End date for the current Supp Health plan rates*
mm/dd/yyyy

Are Domestic Partners included?*

Check To Upload Supp Health Plan Age Banded Rates
Upload Age Banded Rates

Supp Health Plan*
Insurance Carrier
Supp Health Plan Name

Supp Health Plan*
Supp Health Group#
Employer Division (if applicable)

Supp Health Plan(s) Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more

Is a second Supp Health Plan offered?

No

Yes
2nd Supp Health Plan Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more

Upload Age Banded Supp Health Plan Rate Sheet

Drop files here or

Max. file size: 256 MB, Max. files: 3.

Please provide any additional information we should be aware of below

DENTAL PLAN INFORMATION
Is Dental Plan Fully Insured or Self Insured
Does Dental Carrier require monthly paid thru date reports?
Dental carrier enrollment contact*
Please provide the name of the dental insurance carrier, along with the individual or team name to whom reinstatements should be directed.*Note: This should be the enrollment department within the carrier, not the sales, implementation, or customer service contacts.
Dental carrier enrollment contact email (DO NOT enter the broker contact here)*

*It is crucial to provide accurate contact information. This should be the email address for the designated contact to whom reinstatement of coverage requests should be sent.
Coverage will end for Qualified Beneficiaries*
Start date for the current dental plan rates*
mm/dd/yyyy
End date for the current dental plan rates*
em>>mm/dd/yyyy
Are Domestic Partners included?*
Check To Upload Dental Age Banded Rates
Upload Age Banded Rates
1 Dental Plan*
Insurance Carrier
Dental Plan Name

1 Dental Plan*
Dental Group#
Employer Division (if applicable)

1 Dental Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more
Add a second Dental Plan

No

Yes
2 Dental Plan*
Insurance Carrier
Dental Plan Name

2 Dental Plan*
Dental Group#
Employer Division (if applicable)

2 Dental Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more
Add a third Dental Plan

No

Yes
3 Dental Plan*
Insurance Carrier
Dental Plan Name

3 Dental Plan*
Dental Group#
Employer Division (if applicable)

3 Dental Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more
Add a fourth Dental Plan

No

Yes
4 Dental Plan*
Insurance Carrier
Dental Plan Name

4 Dental Plan*
Dental Group#
Employer Division (if applicable)

4 Dental Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more
Upload Age Banded Dental Rate Sheet

Drop files here or

Max. file size: 256 MB, Max. files: 3.

Please provide any additional information we should be aware of below

VISION PLAN INFORMATION
Is Vision Plan Fully Insured or Self Insured
Does Vision Carrier require monthly paid thru date reports?
Vision carrier enrollment contact*
Please provide the name of the medical insurance carrier, along with the individual or team name to whom reinstatements should be directed. *Note: This should be the enrollment department within the carrier, not the sales, implementation, or customer service contacts.
Vision carrier enrollment contact email (DO NOT enter the broker contact here)*

*It is crucial to provide accurate contact information. This should be the email address for the designated contact to whom reinstatement of coverage requests should be sent.
Coverage will end for Qualified Beneficiaries*
Start date for the current vision plan rates*
mm/dd/yyyy
End date for the current vision plan rates*
mm/dd/yyyy
Are Domestic Partners included?*
Check To Upload Vision Age Banded Rates
Upload Age Banded Rates
1 Vision Plan*
Insurance Carrier
Vision Plan Name

1 Vision Plan*
Carrier Name
Group Account Number

1 Vision Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more
Add a second Vision Plan

No

Yes
2 Vision Plan*
Insurance Carrier
Vision Plan Name

2 Vision Plan*
Carrier Name
Group Account Number

2 Vision Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more
Add a third Vision Plan

No

Yes
3 Vision Plan*
Insurance Carrier
Vision Plan Name

3 Vision Plan*
Carrier Name
Group Account Number

3 Vision Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more
Add a fourth Vision Plan

No

Yes
4 Vision Plan*
Insurance Carrier
Vision Plan Name

4 Vision Plan*
Carrier Name
Group Account Number

4 Vision Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more
Upload Age Banded Rate Sheet*

Drop files here or

Max. file size: 256 MB, Max. files: 3.

Please provide any additional information we should be aware of below

Section Break
EAP Plan Information*
Carrier Name
Group / Account Number
Carrier enrollment contact email

Please provide the name of the EAP insurance carrier, along with the individual or team name to whom reinstatements should be directed. *Note: This should be the enrollment department within the carrier, not the sales, implementation, or customer service contacts.
Coverage will end for Qualified Beneficiaries*
Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
Plan Name
EE Only
EE & Spouse
EE & Child
Family
EE + 1
EE + 2 or more

MEDICAL FSA PLAN INFORMATION
Is the FSA Plan Administered by Admin America?*
Please check all FSA benefits that are offered*
Traditional Health FSA Plan
Limited Purpose FSA (LPFSA) - for dental and vision expenses only
FSA Plan Administrator information*
Plan Administrator
Administrator Contact

FSA Contact/Team Email*
Enter Email Confirm Email

FSA Administrator Telephone
FSA Plan Year*
Plan Year Start Date
Plan Year End Date

This refers to the FSA plan year, which does not necessarily need to align with the medical plan policy year.
Please provide any additional information we should be aware of below

HRA PLAN INFORMATION
Is the HRA Plan Administered by Admin America?*
Please check all HRAs that are offered below*
Deductible-Only HRA
Comprehensive HRA
213(d) HRA
Individual Coverage HRA (ICHRA)
Qualified Small Employer Health Reimbursement Arrangement (QSEHRA)
Post-Deductible HRA
Limited-Purpose HRA
Retiree HRA
Excepted Benefit HRA (EBHRA)
Lifestyle HRA (COBRA-eligible)
Deductible-Only HRA : Reimburses only expenses that apply toward the medical plan deductible.

Comprehensive HRA : Covers a broad range of out-of-pocket medical expenses, including copays and prescriptions.

213(d) HRA : Allows employers to reimburse employees for qualified medical expenses under IRS Section 213(d), such as doctor visits, prescriptions, and dental care, on a tax-free basis.

Individual Coverage HRA (ICHRA) : Reimburses premiums and medical expenses for employees enrolled in individual health insurance.

Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) : allows small employers to reimburse employees for individual health insurance premiums and qualified medical expenses on a tax-free basis.

Post-Deductible HRA : Begins reimbursing after a set deductible amount is met; often used with HSAs.

Limited-Purpose HRA : Only reimburses dental and vision expenses; compatible with HSAs.

Retiree HRA : Provides reimbursement for medical expenses incurred by retired employees.

Excepted Benefit HRA (EBHRA) : Reimburses limited benefits (e.g., dental, vision); not for major medical expenses.

Lifestyle HRA (COBRA-eligible) : reimburses for qualified medical expenses under IRS rules. If it only covers general wellness or non-medical expenses (like gym memberships or fitness classes), it is not subject to COBRA continuation.

LIFESTYLE HRA
Does the Lifestyle HRA reimburse for qualified medical expenses?*
A Lifestyle HRA is only COBRA-eligible if it reimburses for qualified medical expenses under IRS rules (e.g., copays, prescriptions, medical services) . If it only covers general wellness or non-medical expenses (like gym memberships or fitness classes), it is not subject to COBRA continuation requirements.
Lifestyle HRAs are only subject to COBRA if they reimburse for qualified medical expenses.

If you selected Lifestyle HRA in the “Please check all HRAs that are offered” section but intended to report a different type of COBRA-eligible HRA, please scroll up and deselect the Lifestyle HRA option. This will allow you to provide the necessary information about your COBRA-eligible HRA(s).

RETIREE HRA
If you are offering a retiree HRA, please upload a copy of the retiree plan summary or plan document.*
Max. file size: 256 MB.

*Required: This documentation is necessary to verify COBRA eligibility and ensure accurate processing.

INDIVIDUAL COVERAGE HRA (ICHRA)
For information on how ICHRA coordinates with COBRA, Click here

Do you have a copy of the 90-day ICHRA Notice provided to employees detailing available benefits and required employer contributions?*
Upload ICHRA contribution rates
Max. file size: 256 MB.

Required: Please upload the employer contribution details

Note: If there are multiple contribution rates (e.g., based on employee location), be sure to upload all applicable rates.
Upload the 90-day ICHRA Notice & employer contributions
Max. file size: 256 MB.

Required: Please upload the 90-day ICHRA Notice & employer contribution details

Note: If there are multiple contribution rates (e.g., based on employee location), be sure to upload all applicable rates.

ICHRA Plan Employee Data
Number of employees eligible for the ICHRA plan
Number of employees currently enrolled in the ICHRA plan

Please provide the total number of eligible employees and the number currently enrolled in the ICHRA plan.

HRA Plan Administrator*
Plan Administrator

HRA Contact Team Email*
Enter Email Confirm Email

HRA Administrator Telephone

HRA Plan Year*
Plan Year Start Date
Plan Year End Date

This refers to the HRA plan year, which does not necessarily need to align with the medical plan policy year.

Coverage will end for Qualified Beneficiaries*
Other:*

Does HRA Administrator require monthly paid thru date reports?
Bundled Enrollment or Ability to Opt-Out Enrollment?*
Option 1 : Opt-Out (Recommended)- Member may choose to Opt-Out of HRA Benefits.
Option 2: Bundled Enrollment- Member cannot Opt-Out of the HRA when enrolled in Medical Plan.

Would you like for Admin America to calculate the HRA rates?*

No

Yes
Admin America HRA calculations

HRA Monthly COBRA Premiums (Do Not Include 2% COBRA Administrative Fee)*
Plan Name
EE Only
EE & Spouse
EE & Child
Family

*Note: Please provide the monthly premiums for the HRA benefit only. Do not include information regarding the Medical Plan premiums.

HRA Benefit - How much does the HRA pay out in total*
Plan Name
EE Only
EE & Spouse
EE & Child
Family

How much does the HRA benefit pay out in total for the Plan Year?

*NOTE: These are NOT the Primary Medical Rates.

Would you like for prior year HRA utilization % to be considered in the rate calculation?

No

Yes

Upload prior year utilization report*
A utilization report for the final year will need to be provided.
Max. file size: 256 MB.

Please provide any additional information we should be aware of below

ADDITIONAL OPTIONAL SERVICES
Additional fees may apply
COBRA Specific Rights Notice Letters*
I agree to the additional charges.
If Recently Terminated Employees (RTE) were terminated more than one month prior to Admin America's effective date for administration and have not yet received their initial COBRA Continuation Coverage Election Notice, a $10.00 charge will apply for each notice that Admin America sends.

EDI Feed

No

Yes
Accept EDI Fees*

Decline EDI Option

COBRA QE/NPM Eligibility Files - $250
Consent*
I agree to the EDI Fees
I Agree to the EDI Fee
EDI Vendor Name
The EDI Vendor Contact should send an email to edi@adminamerica.com to initiate the integration process once the Admin America Welcome Email is received, notifying you that the implementation phase has been finalized.
Note Below Any Additional Information That We Should Be Aware Of

FORM DOWNLOADS/SECURE UPLOAD
ACH Form for Admin Fees
ACH Instructions for Admin Fees
Active Employee & COBRA Member Census Template
*Please include the name of the company on the census for identification purposes.

If you have the member census and/or ACH form ready, you can upload them securely HERE
Otherwise, proceed by clicking "SUBMIT" in the "Signature & Acknowledgments" section to complete your application.

CLIENT SIGNATURE
Applicant First Name*
First
Applicant Last Name*
Last
Applicant Email*
Enter Email Confirm Email

Applicant will receive a copy of the completed application
Please complete the form and rates carefully. Any changes that cause Admin America Inc. to reprocess notifications to Qualified Beneficiaries and/or COBRA participants will result in a $20.00/per participant reprocessing fee.

By entering your name below you are electronically signing this form.

I understand the participant reprocessing fee stating above. The information I have supplied herein is accurate and should be used by Admin America Inc. for COBRA rates as of the date in which Admin America takes over.

Your Name*
Email*

Date*

Signature*
Your Name
Your Name
Your Name

COBRA Abstract

COMPANY INFORMATION

BILLING INFORMATION

BROKER/AGENT INFORMATION

GENERAL RIGHTS NOTICE INFORMATION

DISABILITY EXTENSION

LEVEL OF SERVICE

COBRA THIRD-PARTY ADMINISTRATOR TAKEOVER NOTIFICATION

Medical

MEC (ACA-Supplemental) Plan

Dental Plan

GAP (Supplemental) Plan

Telemedicine (Supplemental) Plan

Vision Plan

Employee Assistance Program (EAP) Plan

Medical FSA Plan

MEDICAL PLAN INFORMATION

MEC PLAN INFORMATION

DENTAL PLAN INFORMATION

VISION PLAN INFORMATION

Section Break

MEDICAL FSA PLAN INFORMATION

HRA PLAN INFORMATION

ADDITIONAL OPTIONAL SERVICES

FORM DOWNLOADS/SECURE UPLOAD

CLIENT SIGNATURE