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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 below
Hourly
Salary
Please select the employee's division:
*
Please select below
M5C5-03C5 Aircap Industries
M5C0-03C0 Commercial Turf Products
M5CB-03CB Consumer
M6CB-0000 Consumer
M5CA-03CA Corporate
M5C1-03C1 Midwest Industries
M5C8-03C8 Modern Transmission Development
M5C7-03C7 MTD Products Inc. Martin
M5C3-03C3 MTD Southwest
M5C2-03C2 Shelby Operations
Divisions for salaried employees.
Please select the employee's division:
*
Please select below
M5G5-03G5 Aircap Industries
M5G0-03G0 Commercial Turf Products
M5GB-03GB Consumer
M6GB-0000 Consumer
M5GA-03GA Corporate
M5G1-03G1 Midwest Industries
M5G8-03G8 Modern Transmission Development
M5G7-03G7 MTD Products Inc. Martin
M5G3-03G3 MTD Southwest
M5G2-03G2 Shelby Operations
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?
*
1
2
3
4
5
6
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:
*
Please select below
Anthem Premium- PREM
Anthem Preferred- PRFM
Medical Tier Type is:
*
Please select below
Single- Single
Single + Spouse- EE + SP
Single + Child(ren)- EE + CN
Family- Family
Does this employee have a dental benefit?
*
Yes
No
Dental Benefit Type is:
*
Dental- DEN
Dental Tier Type is:
*
Please select below
Single- Single
Single + Spouse- EE + SP
Single + Child(ren)- EE + CN
Family- Family
Does this employee have a vision benefit?
*
Yes
No
Vision Benefit Type is:
*
Please select below
Salary Vision- SVIS
Hourly Vision- HVIS
Vision Tier Type is:
*
Please select below
Single- Single
Single + Spouse- EE + 1
Single + 1 Child- EE + 1
Family- Family
Please select QE type below:
*
Please select below
Death of Employee- 100
Divorce- 101
Loss of Dependency- 102
Involuntary Termination- 104
Reduction of Hours- 105
Retirement- 106
Legal Separation- 107
Voluntary Termination- 108
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
Δ