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Below is information about forms and materials you'll commonly use for your plan. For all other forms and materials related to your plan, please log into your account and view the “Forms & Reports” section of My Account Administrator. |
Accessing Forms, Materials and Reports
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Update Contacts Form:
This form is completed to report a change to your company name or address. You may also use this form to add or delete a contact’s name from the Protected Health Information user list or to make a change to the administrative contact, which is the primary point of contact on the account. All reports and correspondence from Employee Benefits Corporation will be sent to the administrative contact.
Download PDF
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Unpaid Leave of Absence Form
This form is completed and returned for all FMLA, Non-FMLA, and USERRA unpaid leaves of absence.
Download Editable PDF |
COBRA Initial Notice Form
The Department of Labor (DOL) requires the Initial Notice for Employers with 20 or more employees. The purpose of the notice is to make employees aware of their rights under COBRA as well as clarify your responsibilities to them and their responsibilities to you. The Initial Notice must be sent to all employees, their spouses and their dependents who are enrolled in any of your group health plans. The Initial Notice should be sent out within 90 days of an employee becoming covered by your group health plan or any time an employee adds a spouse or dependent.
Download PDF |
COBRA Qualifying Event Form
COBRA must be offered to an individual who has experienced a Qualifying Event which is an event that causes a loss of coverage under the group health plan(s). A Qualifying Event Form needs to be completed and submitted to Employee Benefits Corporation within 30 days of a termination, reduction in hours, death of an employee or Medicare entitlement. Events such as a divorce, legal separation or loss of dependent status must be reported within 60 days.
Download Editable PDF |
Certificate of Resolutions Form
Plan design changes require the completion of a Certificate of Resolutions form. Examples of the types of change include but are not limited to: Change group premium accounts, change eligibility rules, change employer contributions, modify the plan design, or modify the plan year. Because this form is specific to your plan, you can find it by logging into your account and viewing the "Forms & Reports" page.
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