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Client Testimonials
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Perfect Referral
Our Services
I Hired an Employee
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COBRA
Employee Information Change
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HR Hotline
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Blog
CBO Report on Establishing a Single Payer System
MN Continuation or MNCOBRA Letter Request Form
This form is requested to provide accurate employee notification for COBRA eligibility. Complete and submit only if Sailer Benefit mails your COBRA Letters. If you have already sent the Change Form please complete and fax back to our office at 651-702-0126. Please email client services with any questions.
Please make sure to Audit your bills and notify your payroll vendors.
Employer Information
*
Indicates required field
Name of Employer
*
Employer Address
*
Line 1
Line 2
City
State
Zip Code
Country
Contact Name
*
First
Last
Employee Information
Effective Date of Change
*
Employee's Name
*
First
Last
Employee's Phone Number
*
Employee's Most Current Address
*
Line 1
Line 2
City
State
Zip Code
Country
Plans Effected -
*
Health
Dental
Group Life
Note: The life insurance carrier will contact the employee for continuation options
Last months health insurance premium billed for employee only $:
*
If none, please put "0" $Dollar amount from the last bill for medical.
Last months health insurance premium billed for dependents of employee $:
*
Last months dental insurance premium billed for employee only dental $:
*
Last months dental insurance premium billed for dependents of employee for dental $:
*
Last months group life insurance premium billed for employee only life insurance $:
*
If none, please put "0"
Additional Information Needed or Requested:
*
We will process this information and mail the COBRA Continuation Rights Notification to the employee with a copy forwarded to you. It is the responsibility of the employer to collect the premium required from the employee. The carriers do not monitor the duration of coverage for COBRA participants-- This is the responsibility of the employer. The participant is responsible for notifying the employer of changes in their situation.
By submitting this form you agree not to hold Sailer Benefit Services, Inc., or any of its employees, liable for incorrect information, errors, or ommissions.
Name
*
Title
*
Date
*
Submit
Home
About
Client Testimonials
Giving Back
Careers
Contact Us
Perfect Referral
Our Services
I Hired an Employee
I Terminated an Employee
COBRA
Employee Information Change
Client Resources
FAQ's
HR Seminar Series
HR Hotline
Privacy Policy
Blog
CBO Report on Establishing a Single Payer System