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COBRA
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COBRA
CDA
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COBRA Reporting for MTD

HR Contact Name*
Email*
Phone*
What type of COBRA event are you reporting?*
- Newly Covered Active Employee * - Send Initial Notice
- Qualifying Event (QE) - Loss of coverage due to termination, divorce, etc.
*Newly Covered Employee - this is for an active covered employee that is newly electing one or more COBRA eligible benefits(s) that has not already been sent a notice
Newly Covered Employee - Send Initial Notice
Employee Name*
First Last
Social Security Number*
Address*
Street Address City State / Province / Region ZIP / Postal Code
By checking the box below, I certify that I am an authorized company representative, that the information submitted online is accurate, and that I authorize NEO to process this request.*
- I agree to the terms and conditions
Qualifying Event (QE)
Employee Name*
First Last
Social Security Number*
Date of Birth*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Is this employee Hourly or Salary?*
Please select the employee's division:*
Divisions for salaried employees.
Please select the employee's division:*
Divisions for hourly employees
Is there a spouse covered on any COBRA eligible benefits?*
- Yes
- No
Spouse's Name*
First Last
Is there a dependent(s) covered on any COBRA eligible benefits?*
- Yes
- No
If yes, how many dependents?*
If more than 6, please add the names in the Additional Comments box below.
Dependent #1*
First Last
Dependent #2*
First Last
Dependent #3*
First Last
Dependent #4*
First Last
Dependent #5*
First Last
Dependent #6*
First Last
Benefit Types and Tier Types
Does this employee have a medical benefit?*
- Yes
- No
Medical Benefit Type is:*
Medical Tier Type is:*
Does this employee have a dental benefit?*
- Yes
- No
Dental Benefit Type is:*
Dental Tier Type is:*
Does this employee have a vision benefit?*
- Yes
- No
Vision Benefit Type is:*
Vision Tier Type is:*
Please select QE type below:*
QE Date (date of event, not end of coverage date)*
MM slash DD slash YYYY
Does this employee have a separation agreement? (MTD to pay COBRA preimums from COBRA Start Date until Separation End Date)*
- Yes
- No
Please indicate the date in which the Separation ends:*
MM slash DD slash YYYY
Please indicate which benefits MTD will pay premiums for:
- Medical
- Dental
- Vision
- Flexible Spending Account (FSA)
Does this employee have a Flexible Spending Account (FSA) in the current plan year?*
- Yes
- No
Additional Comments
By checking the box below, I certify that I am an authorized company representative, that the information submitted online is accurate, and that I authorize NEO to process this request.*
- I agree to the terms and conditions

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Contact Us

CDA: 800-372-3539
CA COBRA: 800-574-5448
OH COBRA: 800-775-3539

Quick Links

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Employer CDA portal
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