Employee’s/Beneficiary’s Notice to Employer of COBRA Qualifying Event
Date of Notice:
Boise School District, ATTN: COBRA Plan Administrator
8169 West Victory Road
(City, State, Zip Code)
Boise, ID 83709
* For most recent address information, check Plan’s most recent Summary Plan Description.
Name of Plan:
The Independent School District of Boise City Group Health Insurance Plan
Covered Employee/Qualified Beneficiary Name and Complete Address:
Date of Qualifying Event:
DIVORCE OR LEGAL SEPARATION, DEPENDENT STATUS, SECOND QUALIFYING EVENT
This notice must be sent to the Plan Administrator after any of the following events occurs. The deadline for providing this
notice is 60 days after the later of (1) the qualifying event or (2) the date on which the qualified beneficiary would lose coverage
under the terms of the Plan as a result of the qualifying event. Please check the appropriate event:
____ A spouse covered under the Plan becomes divorced or legally separated from the covered employee.
____ A child covered under the Plan ceases to be a dependent under the terms of the Plan.
____ The occurrence of a second qualifying event (i.e., spouse becomes divorced/legally separated, child ceases to be
dependent, or employee dies) after the qualified beneficiary has become entitled to COBRA with a maximum duration of 18 or
This notice must be sent to the Plan Administrator after the following event occurs. The deadline for providing this notice is 60
days after the later of (1) the date of the disability determination by the Social Security Administration, (2) the date on which a
qualifying event occurs, or (3) the date on which the qualified beneficiary would lose coverage under the terms of the Plan as a