Fill and Sign the Cobra Letter 497334874 Form

INTRODUCTORY COBRA LETTER Date: ________ Name and Address of Qualified Beneficiary: ________________________________________ Dear ________ : You are eligible for continued health care coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA). Under this law, you may purchase the same medical, dental, and prescription drug coverage provided to current employees for up to 18 months. The attached sheet summarizes the items covered by the medical plan. Your monthly cost is $ ________ for individual coverage and $ ________ for family coverage. Health care benefits under this program will stop automatically at the end of the 18-month period, or sooner if you stop making the payments, become covered under another employer’s health care plan, or become eligible for Medicare. It could also stop if, for some reason, our company discontinues the employee health care plan. Your dependent children automatically receive the same medical coverage as you if you choose to participate. They will have an opportunity to apply for the individual coverage for themselves when they no longer qualify as your dependents. This happens when they reach age 19, when they are no longer full-time students, or sooner, if they get married. If you accept the coverage, you must complete, sign, and mail the enclosed application form to our Human Resources Department within 60 days of receipt of this letter. The premium is due within 45 days of your application for coverage and may be paid monthly or in a single payment. Your payments should also be mailed to the Human Resources Department. If you have any questions about the program or the provision of the law, please write or call me at _____ - _____ . Attached is a more comprehensive explanation of your rights and responsibilities. Sincerely, Human Resources Manager