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COBRA Termination Letter

The Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) allows employees who lose their job to continue their employer sponsored group health insurance coverage for up to 30 months. This coverage can be terminated for a number of reasons including a failure to pay premiums, fraud, and eligibility under part A of part B of Medicare. According to Department of Labor DOL requirements, plan administrators must provide beneficiaries with a written notice of early termination of COBRA coverage, or a COBRA termination letter This allows the individuals to seek new health coverage or to file an appeal with the plan administrator.

Format and Content

A COBRA letter is drafted by the plan administrator with a copy mailed to each qualified beneficiary before the coverage is terminated. The COBRA termination letter format must include the reason why the coverageis being terminated, the rights of the beneficiaries, and the specific date the coverage will end. The letter is customized to fit theD particular plan offered by the company as well as particulars related to the employee. OL regulations require the letter to “be written in a manner calculated to be understood by the average plan participant.”


The person addressed in this COBRA termination letter sample is losing his health coverage due to a failure to pay his premiums on time. He is given notice of his right to appeal as well as the conditions of the appeal. He is asked to direct his questions to the plan administrator.

Dear Mr. Pearson,

This letter contains important information regarding your COBRA continuation coverage. Please read the letter carefully. Your coverage under the Eagle Group Health Insurance Plan, administered by HR services Inc., will cease as of June 15, 2013. According to our records, you did not list any other qualified beneficiaries and therefore, you are the only member of your household covered under this policy.

Your COBRA continuation coverage is being terminated due to the failure to pay your premium on time. If you believe we reached this decision in error you may file an appeal with the plan administrator. Your appeal must be in writing. You may send the appeal letter to Ms. Amy Smith, HR services Inc., 462 Lavon Drive, Miami, Florida 72348.

The letter of appeal must be received by our office within 30 days of the receipt of this termination notice. Please provide a detailed account of your case, including the reasons and documented proof you feel are important to the continuation of your COBRA coverage. Please include your name and contact information. If we do not receive a notice of appeal by the 30-day deadline your COBRA continuation coverage will end on the date specified above.

Please direct any questions to Miss Amy Smith at (555)-555-5555. Alternatively, you may submit your questions in writing at the address given above. Please be aware that any questions submitted by mail will have no effect on the 30-day deadline.


Helen Weiss

Ms. Helen Weiss

HR Services Inc.