COBRA Notification Letters

COBRA NOTIFICATION LETTER

Employer and Plan Identification

Employer Name:

Plan Name:     Plan Sponsor / Administrator:

Employee / Qualified Beneficiary Information

Position Information

Employment History

Education

References

Legal Disclosures

At-Will Employment Statement: The issuance of this notice and any continuation of benefits does not alter the at-will employment relationship between the employer and employee. Employment may be terminated by either the employee or the employer at any time, with or without cause, subject only to the employer's written policies and applicable law.

Equal Opportunity Statement: The employer affirms its commitment to equal employment opportunity and nondiscrimination with respect to all employment practices and benefit administration, including the administration of continuation coverage under the group health plan.

COBRA Notice — Qualifying Event and Coverage Information

This notice is to inform you and your dependents of your right to elect continuation of group health plan coverage under the Plan identified above as a result of a qualifying event. Qualifying Event (check all that apply):

Termination of employment (other than for gross misconduct)     Reduction in hours

Divorce or legal separation     Death of covered employee

Loss of dependent status under the plan     Employee's entitlement to Medicare

Date of Qualifying Event:

Coverage Loss Date:

Maximum Continuation Period (months):

Election Period and How to Elect

You, and any qualified beneficiaries listed below, have a limited period to elect continuation coverage. The election period begins on the later of the date coverage would otherwise end or the date of this notice and continues for the period stated above. To elect coverage, complete the election indicated below and return to the Plan Administrator at the contact address shown above within the time required.

Election (select one): I elect continuation coverage. I decline continuation coverage.

Method of Election Submission (select all that apply): Mail Hand-delivery Fax

Premiums, Payment and Termination of Continuation Coverage

Monthly premium (per covered person): $

First premium payment is due within days after the date of the election. Subsequent premiums are due monthly. Failure to timely pay required premiums will result in loss of continuation coverage as set forth in plan rules.

Other Rights and Important Notices

If a qualified beneficiary becomes entitled to Medicare or enrolls in other group coverage, the continuation period or eligibility may be affected. Certain events, such as a second qualifying event or a disability determination, may extend the maximum period of continuation coverage. Any extension or termination will be administered in accordance with the plan's terms and applicable law. The Plan Administrator will notify you of material changes affecting your rights.

Notice of Special Enrollment Rights: If you do not elect continuation coverage and later lose other group coverage, you may have special enrollment rights under the Plan only as provided by the Plan document and applicable law.

Applicant Certification and Authorization

I certify that all information I provide on this notice and any accompanying election form is true and complete to the best of my knowledge. I authorize the Plan Administrator and employer to obtain such information as may be necessary to administer this continuation coverage, including verification of employment and benefits, and to contact prior employers as necessary to confirm employment and coverage dates.

I understand that a false statement or material omission may result in loss of continuation coverage and may subject me to other remedies available to the Plan or Employer.

Plan Administrator Certification

The undersigned Plan Administrator or authorized representative certifies that the information contained in this notice is accurate to the best of the Plan Administrator's knowledge and that the Plan will administer continuation coverage in accordance with the plan document and applicable law.

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