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Welcome to BASIC COBRA

COBRA Application Renewal

Your Company Information
Company Legal Name*
Company Address*
Phone*
Fax
Contact Person Name*
Contact Person's Email*
Total Number of Employees Enrolled in all Products Subject to COBRA*
Company Insurance*
- Company is fully-insured
- Company is self-insured
Please note that BASIC New England processes ONLY COBRA reinstatements and COBRA cancellations.

The Employer is responsible for processing new enrollments and the initial termination with the insurance carriers
What state is your group medical plans written out of?*
State
If your plans are age rated:
Increases due to birthdays, resulting in rate change, occur
- At renewal
- At the birthday month
Rate Grid(s) - Please upload up to three files (Types accepted: pdf, xls, xlsx, doc, docx, txt, csv, jpg, png):
Max. file size: 500 MB.
Max. file size: 500 MB.
Max. file size: 500 MB.
Broker Information (if applicable)
Insurance Broker Name
Insurance Broker Email Address
Insurance Broker Phone Number
First Medical Carrier and Plan
Name
Group Number
Renewal Date
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations
- Date of Termination
- End of Month
Rates Offered
Single
- Single
Single Rate
Employee and spouse
- Employee and spouse
Employee and spouse Rate
Employee and child(ren)
- Employee and child(ren)
Employee and child(ren) Rate
Family
- Family
Family Rate
Second Medical Carrier and Plan
Name
Group Number
Renewal Date
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations
- Date of Termination
- End of Month
Rates Offered
Single
- Single
Single Rate
Employee and spouse
- Employee and spouse
Employee and spouse Rate
Employee and child(ren)
- Employee and child(ren)
Employee and child(ren) Rate
Family
- Family
Family Rate
Third Medical Carrier and Plan
Name
Group Number
Renewal Date
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations
- Date of Termination
- End of Month
Rates Offered
Single
- Single
Single Rate
Employee and spouse
- Employee and spouse
Employee and spouse Rate
Employee and child(ren)
- Employee and child(ren)
Employee and child(ren) Rate
Family
- Family
Family Rate
First Dental Carrier and Plan
Name
Group Number
Renewal Date
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations
- Date of Termination
- End of Month
Rates Offered
Single
- Single
Single Rate
Employee and spouse
- Employee and spouse
Employee and spouse Rate
Employee and child(ren)
- Employee and child(ren)
Employee and child(ren) Rate
Family
- Family
Family Rate
Second Dental Carrier and Plan
Name
Group Number
Renewal Date
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations
- Date of Termination
- End of Month
Rates Offered
Single
- Single
Single Rate
Employee and spouse
- Employee and spouse
Employee and spouse Rate
Employee and child(ren)
- Employee and child(ren)
Employee and child(ren) Rate
Family
- Family
Family Rate
Third Dental Carrier and Plan
Name
Group Number
Renewal Date
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations
- Date of Termination
- End of Month
Rates Offered
Single
- Single
Single Rate
Employee and spouse
- Employee and spouse
Employee and spouse Rate
Employee and child(ren)
- Employee and child(ren)
Employee and child(ren) Rate
Family
- Family
Family Rate
First Vision Carrier and Plan
Name
Group Number
Renewal Date
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations
- Date of Termination
- End of Month
Rates Offered
Single
- Single
Single Rate
Employee and spouse
- Employee and spouse
Employee and spouse Rate
Employee and child(ren)
- Employee and child(ren)
Employee and child(ren) Rate
Family
- Family
Family Rate
Second Vision Carrier and Plan
Name
Group Number
Renewal Date
Waiting Period for New Hires
Dependent Age Maximum
Full-time Students Age Maximum
Effective Date for Terminations
- Date of Termination
- End of Month
Rates Offered
Single
- Single
Single Rate
Employee and spouse
- Employee and spouse
Employee and spouse Rate
Employee and child(ren)
- Employee and child(ren)
Employee and child(ren) Rate
Family
- Family
Family Rate
FSA Plan Year
Vendor/Contact
HRA Plan Year
Vendor/Contact
Is the premium included in the medical premiums provided?
- Yes
- No
Total utilization for previous plan year, if not the first year
Effective Date for Terminations
- Date of Termination
- End of Month
HRA Category Details
Single Amount Funded
Single Number Enrolled
Two Party Amount Funded
Two Party Number Enrolled
Family Amount Funded
Family Number Enrolled
COMMENTS
Please provide any additional comments you may feel are relevant to your application.

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