BASIC NEO

Home

Participant

COBRA
CDA

Employers

Free Webinars

Regulations

COBRA Reporting

Please use our online secure portal to report your COBRA events. If you have any questions, please email cobraneo@basiconline.com or call us at 1.800.775.3539, option 2.

HR Contact Name*
Company*
Email*
Phone*
What type of COBRA event are you reporting?*
- Please select below
- Newly Covered Employee* - Send Initial Notice
- Qualifying Event (QE)
*Newly Covered Employee - this employee is newly electing one or more COBRA eligible benefit(s)
Newly Covered Employee - Send Initial Notice
Employee Name*
First Last
Social Security Number*
Date of Birth*
Division Name (if tracked by NEO)
Address*
Street Address City State ZIP 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.*
If incorrect information is provided during your submission, causing a notice to be reprocessed and resent, additional fees may be assessed.
- I agree to the terms and conditions
Qualifying Event (QE)
Employee Name*
First Last
Social Security Number*
Date of Birth*
Division Name (if tracked by NEO)
Address*
Street Address City State ZIP Code
Is there a spouse covered on any COBRA eligible benefits?*
- Yes
- No
Spouse's Name*
Spouse's Date of Birth*
Spouse's Social Security Number*
Is there a dependent(s) covered on any COBRA eligible benefits?*
- Yes
- No
Dependent(s) (if any covered) - Use '+' to add each additional dependent
First Name Last Name Date of Birth Social Security Number
Benefit Types and Tier Types - Use '+' to add additional benefit types and tiers*
Benefit Type (Ex. "Anthem PPO Medical Plan" or "Dental High Plan") Tier Type (Ex. Single, Family, etc.)
Reminder: If you are also a BASIC NEO FSA/HRA client, please be sure to report the new hire or termination via the FSA/HRA Reporting Tool by clicking here.
Please select QE type below:*
QE Date (date of event, not end of coverage date)*
MM slash DD slash YYYY
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.*
If incorrect information is provided during your submission, causing a notice to be reprocessed and resent, additional fees may be assessed.
- I agree to the terms and conditions

Welcome to BASIC - CA and Akron, OH Locations

COBRA Reporting

Newly Covered Employee - Send Initial Notice

Qualifying Event (QE)

Contact Us

Quick Links

Benefit Type (Ex. "Anthem PPO Medical Plan" or "Dental High Plan")	Tier Type (Ex. Single, Family, etc.)

First Name	Last Name	Date of Birth	Social Security Number