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Download the Form

This form should be used to advise EHIM when an employee terminates and becomes eligible for COBRA. It will serve as notification to EHIM to send a COBRA letter to employees who qualify for COBRA. This form should only be completed and submitted to EHIM if EHIM is providing COBRA administration services. Please complete all fields of the form in its entirety to help ensure proper notification. You may remit the COBRA Notification Form to EHIM through email or by fax:

Attn: COBRA Department
cobra at

If you have any questions about how to complete the form, please feel free to contact EHIM at 800-311-3446.