Field Definitions: HR Resource COBRA Form

The following is a list of field descriptions for the HR Resource COBRA form. Many of the descriptions include links to other topics that provide additional information about or related to the topic.

Resource #

Enter the resource (as defined in HR Resources) for whom you are setting up this COBRA information.

Dependent Seq #

Enter the dependent’s sequence number. If defining COBRA benefits for the employee, this number should be ‘0’ (zero). (Note: The description for dependent sequence number ‘0’ will be “Same as Resource Number”.)If defining COBRA benefits for an employee’s dependents, this number should be the number assigned to the dependent in HR Resource Dependents.

Health Coverage Term Date

Enter the date that this employee’s normal health coverage terminates.

Eligibility Date

Enter the date that this employee is eligible for COBRA benefits.

Qualifying Event

Using the drop-down list, specify the event that qualifies this employee or employee’s dependent to receive COBRA benefits. Options available are:

T - Termination of employment

D - Death of employee

S - Divorce or legal separation

E - Employee entitled to Medicare

Q - Covered dependent ceasing to qualify

Qualifying Event Desc

Enter an additional description of the event indicated above, up to 30 characters. For example, if you selected option ‘T’ above, you might enter lay-off, termination, retired, etc.

Qualifying Event Date

Enter the date that the qualifying event took place.

Date Notice Sent

Indicate on what date the notice of eligibility was sent.

Enrollment Date

Specify on what date this employee was enrolled in the COBRA plan.May be left blank if coverage was declined.

Coverage Selected

Required if Enrollment Date specified.

Specify the COBRA coverage plan selected, up to 30 characters.

Compliance Date

Required if Enrollment Date specified.

Enter the date COBRA compliance requirements were met.

Start Date

Required if Enrollment Date specified.

Enter the date COBRA benefits start.

End Date

Required if Enrollment Date specified.

Enter the date COBRA coverage ends. When first adding a record, initially defaults a value as follows:

  • If qualifying event is 'Death of Employee' or 'Divorce or Legal Separation', default is 36 months from 'Start Date'

  • If qualifying event is 'Termination of Employment', 'Employee Entitled to Medicare', or 'Covered Dependent Ceasing to Qualify', default is 18 months from 'Start Date'.

COBRA Discontinued Date

Enter the date COBRA coverage was discontinued, if applicable.

COBRA Declined Date

Enter the date the COBRA coverage was declined.

Company Paid Premium

Enter the premium amount paid by the company for COBRA benefits.

Employee Paid Premium

Enter the premium amount paid by the employee for COBRA benefits.

Total COBRA Payments

Display only, the total premium amount paid for COBRA benefits by employee and employer.