COBRA Compliance Risk QuestionnaireThis questionnaire is designed to help employers identify potential compliance risks related to COBRA administration and continuation coverage obligations. It is intended as an educational and discovery tool and does not constitute legal or tax advice.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Company Information Company Name: *Compliance Officer: *Section 1 – COBRA Applicability 1. Did your organization employ 20 or more employees on at least 50% of your typical business days during the previous calendar year? If no, you will skip to Section 4. choose answerYesNo2. Do you currently offer group health coverage to employees?choose answerYesNo3. Which benefits are offered and potentially subject to COBRA?MedicalDentalVision4. Have you determined whether any state continuation requirements apply to your organization?choose answerYesNoSection 2 – COBRA Administration 1. Who currently administers COBRA?2. Is there a written process for handling COBRA qualifying events?choose answerYesNo3. Are qualifying events tracked consistently?choose answerYesNo4. How are employee terminations communicated to the COBRA administrator?Section 3 – Qualifying Event Administration 1. Which qualifying events are currently tracked?Job LossReduction in HoursDivorce or SeparationDeathDependent aging outOther2. Have there been any missed COBRA elections or late notifications in the past 24 months?choose answerYesNo3. Have any former employees complained about COBRA administration?choose answerYesNo4. Have you ever received legal correspondence or penalties related to COBRA?choose answerYesNoIf yes, please explain:Section 4 - Important Disclosure : This questionnaire is intended for informational purposes only and should not be construed as legal, tax, or regulatory advice. Employers should consult qualified legal counsel or compliance professionals regarding their specific situation. Name *FirstLastDateSubmit
