COBRA Qualifying Event Form - Sterling HSA 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Company Name and Date Submitted at the top of the form. This identifies the employer responsible for submitting the form.
3. Fill in the Employee Name, SSN, Address, City, State, Phone, Date of Birth, Marital Status, and Gender. Ensure all personal information is accurate for proper processing.
4. List any covered family members by providing their names, social security numbers, and birth dates in the designated section.
5. In the Qualifying Event Information section, enter the Qualifying Event Date and Date Active Coverage Terminates. Select the type of COBRA event that applies by checking one of the options provided.
6. Complete the Current Eligible Benefits section by indicating whether there are Medical HRA or FSA benefits available and provide details such as monthly premium and original effective date.
7. Finally, ensure that you have answered whether the employee had at least 18 months of previous group health plan coverage. Sign and date where indicated to complete your submission.

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