EBSA 300 Application to the U. S. Department of Labor for Expedit

Application to the U. S. Department of Labor
for Expedited Review of Denial of
COBRA Premium Reduction
GENERAL INFORMATION: If you or a family member has lost employment, the American Recovery and Reinvestment Act
of 2009 (ARRA) may make it possible for you to keep your employment-related health coverage. The Act provides for
premium assistance for health benefits under the Consolidated Omnibus Budget Reconciliation Act of 1985, commonly
called COBRA. The premium assistance is also available for continuation coverage under certain State laws. For coverage
periods beginning on or after February 17, 2009, assistance eligible individuals pay only 35% of their continuation coverage
premiums to the plan for the first fifteen months. The remaining 65% is reimbursed to the plan, employer, or health
insurance issuer through a payroll tax credit. The Department of Defense Appropriations Act, 2010 (2010 DOD Act)
extended the eligibility period for the COBRA premium reduction from December 31, 2009 to February 28, 2010 and the
maximum period for receiving the subsidy from nine to fifteen months.

To be considered and “Assistance Eligible Individual” and receive reduced premiums you:
♦ MUST have a continuation coverage election opportunity related to an involuntary termination of employment
that occurred at any time from September 1, 2008 through February 28, 2010;
♦ MUST elect the coverage (within the appropriate timeframes);
♦ MUST NOT be eligible for Medicare; AND
♦ MUST NOT be eligible for coverage under any other group health plan, such as a plan sponsored by a successor
employer or a spouse’s employer.
Note: The 2010 DOD provides an extended period of time to make reduced payment for certain periods of coverage. If you
have reached the end of the original reduced premium period and have additional months of continuation coverage
available, you can make a retroactive payment of the reduced premium(s) for the period(s) of coverage immediately
following what would have been the last period of the reduced premium reduction. This payment must be made by the
later of February 17, 2010, 30 days from the date this notice was provided to you, or the end of the otherwise applicable
payment grace period.
The applicant (person requesting review of a denial of premium assistance) may either be the former employee or a
member of the employee’s family who is eligible for COBRA continuation coverage or the COBRA premium assistance
through an employment-based health plan. The employee and his/her family members may each elect to continue health
coverage under COBRA, request the premium assistance, and request a review of a denial of premium assistance.
If you believe you are eligible for COBRA continuation coverage and for this premium reduction through a private sector
health plan sponsored by an employer generally with at least 20 employees, but your request for these benefits or the
reduced premium has been denied, you may apply to the U.S. Department of Labor to review the denial. If your
continuation coverage is provided through a Federal, State or local government plan, or if it is provided pursuant to State
insurance law, you should direct your request for review to the Department of Health and Human Services or access their
website at www.cms.hhs.gov/COBRAContinuationofCov/.

APPLYING FOR REVIEW: Answer all of the questions on the application to the best of your knowledge and ability. If
you don’t know the answer to a question you may check the box marked “Unsure or N/A.” (N/A stands for “not
applicable.”) The red asterisk (*) denotes required information. Please include copies of any documents that you think
would help the Department in its review of your application, examples of which are listed in the attached instructions.
Provide your complete contact information (daytime phone number, an alternate phone number, and an email address, if
available) so that the person reviewing your application can contact you with any questions or if additional information
is needed. The Department of Labor will not review your denial until you submit a properly completed application form.
A separate application(s) must be completed for any family member whose plan information is not identical to the
information you provide. Keep a copy of the application(s) submitted for your records. NOTE: In the course of its
review, the Department may need to share information on this application with your employer or plan administrator.
You are encouraged to complete your application online at www.dol.gov/COBRA or, you can fax or mail this completed
application, along with your attachments, to:
Fax to:

U.S. Department of Labor, EBSA
Attn: COBRA Appeals
Fax number: 202-693-8849

Mail to:

U.S. Department of Labor, EBSA
Attn: COBRA Appeals
PO Box 78038
Washington, DC 20013-9038

FOR ASSISTANCE: If you have questions on how to complete this form or about eligibility for COBRA or the COBRA

premium reduction, please see our website at www.dol.gov/COBRA. You may also call a DOL Benefits Advisor toll-free at
1-866-444-3272. Benefits Advisors can assist you with questions, but cannot complete or take your application for
review by phone.

Attention: Before you get started, do a quick check on your eligibility for the COBRA premium reduction.
If √ you were covered by the employer’s group health plan on the last day of the employee's
employment*;
√ there is an ongoing health plan responsible for providing COBRA continuation coverage;
√ your qualifying event was the employee’s involuntary**job termination that occurred during the
period beginning September 1, 2008 through February 28, 2010 and not divorce, legal separation,
entitlement to Medicare, loss of dependent status, or death of the covered employee,
then you may be eligible for the COBRA premium reduction.
NOTE: If your coverage is provided by a plan sponsored by the Federal government, or a state or local
government (such as public schools, public colleges and universities, or police or fire departments), you
must file your application for review with HHS. See www.cms.hhs.gov/COBRAContinuationofCov/
If you have questions on how to complete this application or about eligibility for COBRA or the COBRA
premium reduction, please see our website at www.dol.gov/COBRA. You may also call a DOL Benefits
Advisor toll-free at 1-866-444-3272. If you feel that you have been inappropriately denied the COBRA
premium reduction, complete the attached application.
* Note: newborns, adopted children or children placed for adoption added through special enrollment count
as if they were on the plan on the last day of the employee’s employment.
** For help in determining what job loss situations are involuntary terminations, see the IRS guidance at
ww.irs.gov/pub/irs-drop/n-09.27.pdf.

Application to the U. S. Department of Labor
for Expedited Review of Denial of
COBRA Premium Reduction

OMB Control Number
XXXXXXXXXXX
Exp. Date
OMB Control
Number 1210-0135
Exp. XX/XX
Date 11/30/2012

Applicant’s Information
Mr.
Mrs.
*Name

* Denotes required information
Ms.

Last

First

Middle Initial

*Street Address
State

*City
*Best phone number to
reach you during business
hours:

Home

Work

Cell

Alternate phone
number:

Zip code
Home

Work

Cell

Email Address:

Date of termination of insurance or group
health plan benefits, if any:
(month/day/year)
/
/

*Date employment was terminated:
(month/day/year)
/

/

Applicant’s relationship to employee:
Self
Spouse
If applicant is not the employee, provide name of employee:

*Name
Last

Mr.

Mrs.

Child

Other (explain)

Ms.
First

Middle Initial

Names of dependents for whom you are also requesting a determination regarding a denial of COBRA premium reduction, if
any. Reminder: If the plan information for any family member is not identical to your information, complete a separate
application for them.
Name
Relationship
Age
D1)
D2)
D3)
D4)
Attach an additional page if you need to add more dependents to the list

Eligibility: Please see instructions for assistance in answering the questions below.

Yes

No

Unsure
or N/A

*1. On the last day of you or your family member’s employment, were you covered by a group
health plan at work? If you acquired a new dependent (or dependents) by birth, adoption or
placement for adoption, refer to the instructions to answer the question for your new dependent.
*2. Did the employee’s job termination occur from September 1, 2008 through
February 28, 2010.
EBSA 300
3/2009

Yes

No

Unsure
or N/A

*3. Is there an ongoing health plan that covers employees where you or your family member used to
work? Note: The plan could be sponsored by the former employer, union or joint board of trustees or
another employer who may be responsible for providing COBRA continuation coverage to you.
*4. Are you eligible for COBRA because of your or your family member’s job loss? If so, answer YES.
If you are eligible for COBRA because of divorce, legal separation, entitlement to Medicare, loss of
dependent status, or death of the covered employee, answer NO.
PLEASE NOTE: If you answered NO to any of the Questions above (1-4) you may not be eligible for the COBRA premium
reduction. If you have questions about the requirements for COBRA or for the COBRA premium reduction, or otherwise
need assistance completing this application, please contact a Benefits Advisor toll-free at 1-866-444-3272.
Yes No Unsure
or N/A
*5. Was your or your family member’s job termination involuntary?
Yes

No

Unsure
or N/A

a. Was it a permanent layoff?
b. Was it a layoff with possible recall or a temporary furlough?
c. Was it a buyout or severance package in anticipation of a layoff?
d. Did the employee resign as a result of a change in the geographic
location of employment?
e. Did the employee’s employment end while the employee was absent
due to illness or disability?
f. Other - please describe in the Other Information box at the end of the
application.
For more information that may help you to answer these questions, see Questions 1-9 of the IRS
Notice 2009-27 at www.irs.gov/pub/irs-drop/n-09-27.pdf.

*6. Regarding the entity who sponsors your or your family members’ group health plan:
a. Did you or your family member work for the Federal government, a State government, or
local government such as a public school system, a public college or university or a police or fire
department? If yes, you should file your application for review with HHS. See
www.cms.hhs.gov/COBRAContinuationofCov/
b. Did you or your family member work for a Church (including daycares, hospitals, and other
facilities run by religious organizations)? If yes, you should first contact the applicable state
department of insurance to see if the plan is subject to state continuation. If the state law does
apply, you can file your application for review with HHS. See above.

*7. Do you believe that your or your family member’s former employer had 20 or more employees
in the calendar year prior to the employee’s job termination?
*8. Regarding COBRA coverage:
a. Did you receive a notice informing you of your right to elect COBRA?
b. Did you send in a form requesting, or electing, COBRA coverage?
c. Were you denied COBRA coverage? If yes, explain the reason in the Other Information box at
the end of the application. Attach copies of all relevant documents.

*9. Regarding the COBRA premium reduction:
a. Did you receive a notice informing you of your right to a premium reduction?
b. Did you receive a notice informing you about the premium reduction extension and the
opportunity to retroactively pay certain unpaid reduced premiums related to the extension
from 9 to 15 months?
c. Were you denied the premium reduction or granted the premium reduction, but denied the
additional 6 months of premium reduction provided by the extension? If yes, explain the
reason in the Other Information box at the end of the application below. Attach copies of all
relevant documents.

*10. At any time after you or your family member became unemployed were you (or any
dependents) eligible for coverage under any other group health plan (such as a plan sponsored by a
later employer or a spouse’s employer) or Medicare? If yes, please note the date you (or any
dependents) became eligible for the other coverage.
/

/

Fill in the information below that applies to you.
Plan Sponsor Information: Please enter the following information about the employer, union, or joint board of trustees
that sponsors the group health plan as completely as possible and attach any supporting documentation you have. Note:
This information may be found on the COBRA notice you received.
*Name of Plan Sponsor
Best Person at Plan Sponsor to Contact:

Mr.

Mrs.

Ms.
First

Last

*Street Address
State

*City

Zip code

Fax number:

*Phone number:

Plan Sponsor’s E-mail Address:

Plan Sponsor’s Web site address:

Yes

Employer Information: If the plan sponsor is not the employer, please enter the

No

Unsure

following information about the employer.

*Name of Employer
Best Person at Employer to Contact:
Last

Mr.

Mrs.

Ms.

First

*Street Address
*City
*Phone number:

Employer’s E-mail Address:

State
Fax number:

Zip code

Employer’s Web site address:

If you believe another entity such as a parent company or a company that acquired your former employer may be
responsible for providing COBRA continuation coverage, please provide as much information about the company and the
circumstances as possible. (Attach an additional sheet, if needed)
Parent Company or Purchaser’s Name
Best Person at Parent Co. to Contact:
Last

Mr.

Mrs.
First

Ms.

Street Address

City

State

Phone number:

Zip code

Fax number:

Parent Co./Purchaser’s E-mail Address:
Parent Co./Purchaser’s Web site address:

Insurance, HMO or Benefits Administrator Information: If applicable, please enter the following information about the
insurance company, HMO, or benefits administrator that administers benefits for your group health plan as completely as
possible and attach any supporting documentation you have.
*Name of Plan (ex. ABC Insurance Co PPO, Big Company Group Plan)
Name of Insurer, HMO or Benefits Administrator:
Best Person to Contact:

Mr.

Last

Mrs.

Ms.
First

Street Address
City

Phone number:

Group Number of Insurance/Plan:

State

Fax number:

Applicant’s Plan ID number:

Zip code

Under penalty of perjury, I declare that I have examined this application, including any accompanying attachments, and
to the best of my knowledge and belief, it is true, correct and complete. I hereby authorize the release of the information
contained in and attached to this application, as well as any additional oral or written information that may be collected
in connection with this review process, to any other parties to this review, including the health plan and the employee’s
former employer. I further authorize the individuals involved in processing this review to discuss with other individuals
such information as they may deem necessary in resolving this review.
Signature:

Date:

Type or print name:

Other information : **IMPORTANT** Please provide what you were told about the reason(s) you were denied COBRA
continuation coverage and/or the premium reduction as well as any other information you believe is important for the
Department of Labor to know in order to evaluate your application. Since the Department’s review cannot begin until we
have a complete application, please attach copies of documentation that you believe would assist the Department in making
a determination regarding your application. Such documentation could include copies of one or more of the following
items:
• Your COBRA election notice,
• Your “Request for Treatment as an Assistance Eligible Individual” or other form used to request the premium
reduction,
• Your insurance card,
• Payroll stubs showing deductions for health benefits,
• Any documents detailing the date and circumstances of the termination of the employee’s employment, or
• Any documentation you were provided regarding the denial of the premium reduction.

Privacy Act Notice
The Privacy Act of 1974 requires that when we ask you for information we tell you our legal right to ask for the information, why we are
asking you for it, and how it will be used. We must also tell you what could happen if we do not receive it and whether your response is
voluntary, required to obtain a benefit, or mandatory. Our legal right to ask for the information is section 3001(a)(5) of the American
Recovery and Reinvestment Act of 2009 (ARRA) P.L. 111-5, as amended by the Department of Defense Appropriations Act, 2010, P.L.
111-118. We are asking for this information to comply with the provisions of ARRA and to enable the Secretary of Labor to make a
determination on your application for the Secretary’s expedited review of the denial of your request for treatment as an assistance
eligible individual. If you do not provide the requested information, you will not be eligible for such review. We do not sell the
information that we collect. The personal information that you give us will be used only in connection with the Secretary’s expedited
review of the denial of your request for treatment as an assistance eligible individual.
We use contractors to perform various website and database functions. When we do, we make sure that the agreement language with the
contractor ensures the security, confidentiality and integrity of any personal information to which the contractor may have access in the
course of contract performance.
While online filing is secure, electronic mail is not secure. Therefore, we suggest that you don’t send personal information to us by
email. We will only send general information to you by email.
We may disclose the information you give us if authorized or required by Federal law, such as the Privacy Act. We may also disclose
this information to the other parties to this review, including your health plan and, in many cases, to the employee’s former employer, as
well as to the courts as a part of the record on any appeal. You may have access to any of the information we collect about you. Also, if
you provide false or fraudulent information, you may be subject to criminal prosecution. See section 1027, Title 18, U.S. Code (False
statements and concealment of facts in relation to documents required by ERISA) and section 1001, Title 18, U.S. Code (Fraud and
False Statements - Statements or entries generally). Other penalties may also apply.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such
collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average one
(1) hour per response, including time for reviewing instructions, gathering the data needed, and completing and reviewing the collection
of information. The obligation to respond to this collection is required to obtain or retain benefit (see section 3001(a)(5) of the American
Recovery and Reinvestment Act, P.L. 111-5, as amended by the Department of Defense Appropriations Act, 2010, P.L. 111-118).
Please send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the U.S. Department of Labor, Office of the Chief Information Officer, Attention: Departmental Clearance
Officer, 200 Constitution Avenue, N.W., Room N-1301, Washington, DC 20210 and reference OMB Control Number. Note: Please do
not return the completed application to this address.

Instructions for the Application to the U.S. Department of Labor for
Expedited Review of Denial of COBRA Premium Reduction as Provided by
the American Recovery and Reinvestment Act of 2009
Please provide the required information where you see a *. All other information is optional but will assist the
Department in its review.
Contact Information Please complete the fields, if filing by mail or fax, by entering one letter or number per
box. Please print clearly as demonstrated.
Mr.

*Name

X Mrs.

Ms.

Last

S

First

M I

T

H

J

Middle Initial

O

H

N

*Street Address

1

2

*City
A N

3

4

M A

P

L

E

L

A

N

E
State

Y

T

O

W

N

S

Zip code

T

9

8

7

6

5

Lines D1-D4 When adding information on your dependents, please remember that a separate application(s)
must be completed for any family member whose information is not identical to the information you provide.
Please answer Questions 1-10 by placing an X in the appropriate box (

X

).

Question #1 Answer YES to this question if you were covered by the group health plan. If you were not
enrolled but should have been, answer UNSURE and explain the circumstances in the other information section
at the end of the application. If you acquired a new dependent (or dependents) by birth, adoption, or placement
for adoption at any time after the date of the qualifying event and you made a timely request to special enroll
the new dependent(s), answer YES to this question.

Question #2 Answer YES if the employee’s job termination occurred from September 1, 2008 through
February 28, 2010. Answer NO if the termination occurred before September 1, 2008 or after February 28,
2010.

Question #3 Answer YES if you have an ongoing health plan, if your former employer was acquired by
another business that provides group health benefits, or if the employee's former employer was a "trade or
business" under common control. The acquiring business or other employers in the control group may have
to offer you COBRA continuation coverage. If these situations do not describe your health plan, answer NO to
this question. If you answer NO, you may have no plan from which to obtain COBRA continuation coverage.
If so, the premium reduction would not apply.

Question #4 For purposes of the premium reduction, COBRA qualifying events such as divorce, legal
separation, entitlement to Medicare, a child ceasing to be a dependent child under the terms of the plan, or
death of the employee are not terminations of employment.

Question #5 To be eligible for the COBRA premium reduction, the employee's job termination must have been
involuntary. Whether a termination of employment is an involuntary termination of employment is
determined based on all the relevant facts and circumstances. Examples of situations that may constitute an
involuntary termination of employment are listed in Question 5. For help in determining if other situations
are involuntary terminations, see the IRS guidance at www.irs.gov/pub/irs-drop/n-09-27.pdf. Check the
appropriate box that describes your situation. If none of the examples address your termination, answer YES in
Item 5f and describe the circumstances of your termination in the Other Information box at the end of the
application. Also please note: An employee and his or her dependents may not be eligible for COBRA
continuation coverage if the employee was terminated from employment for gross misconduct.

Question #6 If you were employed by a private-sector employer, answer NO.
Government Plans: If your benefits were provided by the Federal government (under Temporary Continuation
Coverage (TCC) of the FEHBP), a State or local governmental plan (such as a public school, a public college or
university or a police or fire department) answer YES. If you answered YES to this question, the Department
of Labor may not have jurisdiction to review your request for review. You should send an application for
review to the Department of Health and Human Services. Instructions on how to submit such an application
may be found at www.cms.hhs.gov/COBRAContinuationofCov.
Church Plans: If your benefits were provided by a Church plan (including religious organizations, or daycares,
hospitals or other facilities operated by religious organizations) it would not be subject to the COBRA
continuation coverage requirements under Federal COBRA and the Department of Labor does not have
jurisdiction over the plan to issue a determination letter. If a plan sponsored by a church or church
organization chooses to provide COBRA benefits absent a legal requirement, participants are ineligible to receive
any ARRA COBRA premium reduction (see IRS Notice 2009-27, Q & A 16).
Church plans may be subject to state continuation laws. You should check with your state department of
insurance to see if your state has a continuation coverage law that would cover a church plan. You can find
the contact information for your state department of insurance on the National Association of Insurance
Commissioners’ website at: http://ww.naic.org/state_web_map.htm. If you believe your church sponsored
plan is subject to state continuation, you can file an appeal with HHS (see above).

Question #7 Answer based upon the number of employees you believe your employer had. We recognize that
you may not have the information to confirm this response. Generally, Federal COBRA only applies to group
health plans maintained by employers that had at least 20 employees on more than 50 percent of its typical
business days in the previous calendar year, counting full- and part-time employees.
Please note: Although Federal COBRA rules do not apply to these small employers, the COBRA premium
reduction applies to comparable continuation coverage that is provided pursuant to State law. If you answer
NO to this Question indicating that your employer had fewer than 20 employees, your plan may be providing
comparable State coverage. Contact the Department of Health and Human Services (HHS) at
www.cms.hhs.gov/COBRAContinuationofCov to determine whether State law applies to your coverage and
whether you can file an application with HHS for review.

Question #8 If you were offered COBRA continuation coverage in connection with your or your family
member's job, select the answer that best addresses the status of your COBRA election. The COBRA election
notice should be provided to qualified beneficiaries within 44 days of a qualifying event and should include
information to help you understand COBRA coverage, including the name of the plan's COBRA administrator.
If you received such a notice, answer YES. You must be given an election period of at least 60 days (starting
on the later of the date the notice was sent to you or the date you would lose coverage) to choose whether or
not to elect COBRA continuation coverage. Did you let your plan know that you elected COBRA continuation
coverage? If so, answer YES. If you requested COBRA continuation coverage but were denied, your plan must
provide a notice within 14 days after receiving your request and the notice must explain the reason for
denying your request. Refer to this notice to answer the question and provide the reason in the Other
Information section at the end of the application and attach a copy of the notice with your application.
Note that ARRA added a second election period for some individuals who experience an involuntary job
termination from September 1, 2008 through February 17, 2009. If these individuals did not elect COBRA
continuation coverage on their first opportunity, or elected COBRA continuation coverage but dropped it, they
had a second opportunity to elect it.

Question #9 Answer Yes if you received a COBRA notice or additional notices that contained the information
indicated in the question.
If you were denied the COBRA premium reduction in full or in part, your plan may have provided you written
notification of the reason for the denial, possibly on the form you used to request the premium reduction. If
so, refer to that document to provide the reason in the Other Information section at the end of the application

and attach a copy of the document with your application. If you have received no response to your request,
you should answer "Unsure."

Question #10 Answer YES if you are eligible for coverage under another group health plan or Medicare
benefits. If you answer YES to this Question, you are not eligible for the premium reduction on the first date of
eligibility for the other coverage. Note: If you are eligible for the premium reduction, you are required to
notify the plan when you become eligible for Medicare or other group health coverage. Failure to do so may
subject you to a tax penalty of 110 percent of the amount of any premium reduction.

Information on your plan sponsor/employer, insurance company, and/or plan administrator Refer to the
COBRA notice you received to find the information to use for this application. Attach a copy of the COBRA
notice to your application.
Other Information Please provide what you were told about the reason(s) you were denied COBRA
continuation coverage and/or the premium reduction as well as any other information you believe is important
for the Department of Labor to know in order to evaluate your application.

Attachments Since the Department’s review cannot begin until we have a complete application, please attach
copies of documentation that you believe would assist the Department in making a determination regarding
your application. Such documentation could include copies of one or more of the following items, if relevant
and applicable: your COBRA election notice, your Request for Treatment as an Assistance Eligible Individual or
other form used to request the premium reduction, your insurance card, payroll stubs showing deductions for
health benefits, any documents detailing the date and circumstances of the termination of the employee’s
employment, or any documentation you were provided regarding the denial of the premium reduction.
If you submit attachments for this application after submitting the application or if you fax or mail
attachments for an online application, be sure to clearly print your name and phone number on the first page of
any document you send. If you know your control identification number please print that as well.