<% Option Explicit Dim strCompany Dim strReqby Dim strOther strCompany = Request.Cookies("Company") strReqby = Request.Cookies("Reqby") If strCompany = "" Then strCompany = Request("Contact_Organization") End If %> COBRA Notification

COBRA Notification Request

This form is to notify HR Butler and TR Hedge that a COBRA Letter must be sent to an individual.

Employer Name:  
Your Name:  
E-Mail Address:  
   

  This is a New Hire Notification Request

Please provide the following Employee Information for the COBRA Notification:
     * All Dates must be in the MM/DD/YY format
    ** If Qualifying Event is due to Divorce, Provide SSN and Home Mailing address of Ex-spouse

Social Security Number   DOB    * 
Date of Hire   Gender Male Female
Last Name  

First Name

  
Address
City, State Zip		  
Qualifying Event ?  

If Other

  
Date of Qualifying Event   *           
Benefit Start Date   * 

Benefit End Date

   * 
Medical Plan  

Coverage

 

Medical Plan Type 

       
Dental Plan  

Coverage

  

Dependent(s):

Relationship  

Name  

Birth Date * 

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

     

Additional Notes / Comments:

If there are more than 11 dependents, please contact us.

<% Response.Cookies("Company") = strCompany %> <% Response.Cookies("ReqBy") = Request("RequestedBy") %> <% Response.Cookies("HREM") = Request("EMailAddress") %>
<% Response.Write Request.Cookies("Company")%>