Paychex cobra 2026

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The COBRA Employee Datasheet is a form used to document and process the loss of health insurance coverage for employees and their dependents due to qualifying events. It requires detailed information about the individuals affected, the nature of the qualifying event, and the insurance plans involved. The completed form must be submitted to Paychex within 30 days to ensure continuation of coverage.

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Click ‘Get Form’ to open the paychex cobra document in the editor.
Begin by entering the COMPANY/CLIENT NAME and OFFICE/CLIENT ACCT. # at the top of the form.
List any individuals being removed from insurance under 'Employee & Dependent Name(s)', including their Gender, Birthdate, and Address.
Indicate Medical Enrollment and Tobacco Use for each individual listed by selecting 'YES' or 'NO'.
Fill in the EMPLOYEE TELEPHONE # and DEPENDENT TELEPHONE # if different. Then, specify the Date of Qualifying Event.
Select the qualifying event that caused loss of coverage eligibility from the provided options.
Complete the COBRA Insurance section by listing plans currently enrolled in and filling out requested information.
Finally, provide your AUTHORIZED COBRA CONTACT SIGNATURE and DATE before submitting the completed form to Paychex via email, fax, or mail.

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