Sample COBRA notice of initial rights

The following sample form may be used by employers, employee organizations and plan administrators to notify covered employees and spouses of their rights under COBRA. This model form was issued by the Employee Benefits Security Administration (EBSA) as part of final regulations (69 FR 30083, May 26, 2004). Before relying on this form, consult an attorney or benefits professional to make certain that the form fits your particular needs or factual circumstances and reflects the latest guidance issued by the IRS.

Model General Notice of COBRA Continuation Coverage Rights (Adobe PDF)
Model General Notice of COBRA Rights.pdf