COBRA Notification to Terminated Employee

COBRA Continuation Coverage Election Notice

(For use by single-employer group health plans)

Dear :

This notice contains important information about your right to continue your health care coverage in the (the Plan).

Please read the information contained in this notice very carefully. To elect COBRA continuation coverage, follow the instructions on the next page to complete the enclosed Election Form and submit it to us.

If you do not elect COBRA continuation coverage, your coverage under the Plan will end on due to (Check Appropriate Box):

End of employment

Reduction in hours of employment

Death of employee

Divorce or legal separation

Enrollment in Medicare

Loss of dependent child status

Each person ("qualified beneficiary") in the category(ies) checked below is entitled to elect COBRA continuation coverage, which will continue group healthcare coverage under the Plan for up to months.

Employee or former employee

Spouse or former spouse

Dependent child(ren) covered under the Plan on the day before the event that the loss of coverage

Child who is losing coverage under the Plan because he or she is no longer dependent under the Plan

If elected, COBRA continuation coverage will begin on and can last until .

You may elect any of the following options for COBRA continuation coverage:

COBRA continuation coverage will cost:

You do not have to send any payment with the Election Form. Important additional information about payment for COBRA continuation coverage is included in the pages following the Election Form.

If you have any questions about this notice or your rights to COBRA continuation coverage, you should contact

COBRA Continuation Coverage Election Form

Instructions: To elect COBRA continuation coverage, complete this Election Form and return it to us. Under federal law, you must have 60 days after the date of this notice to decide whether you want to elect COBRA continuation coverage under the Plan.

Send completed Election Form to:

This Election Form must be completed and returned by mail . If mailed, it must be post-marked no later than .

If you do not submit a completed Election Form by the due date shown above, you will lose your right to elect COBRA continuation coverage. If you reject COBRA continuation coverage before the due date, you may change your mind as long as you furnish a completed Election Form before the due date. However, if you change your mind after first rejecting COBRA continuation coverage, your COBRA continuation coverage will begin on the date you furnish the completed Election Form.

Read the important information about your rights included in the pages after the Election Form.

I (We) elect COBRA continuation coverage in (the Plan) as indicated below:

I (We) elect to continue our coverage in the (the Plan) as indicated below:

Name:

Date of Birth:

Relationship to Employee:

SSN (or other identifier):

Coverage option elected:

[Add if appropriate]

Name:

Date of Birth:

Relationship to Employee:

SSN (or other identifier):

Coverage option elected:

[Add if appropriate]

Name:

Date of Birth:

Relationship to Employee:

SSN (or other identifier):

Coverage option elected:

[Add if appropriate]

Name:

Date of Birth:

Relationship to Employee:

SSN (or other identifier):

Coverage option elected:

[Add if appropriate]

Important Information About Your COBRA Continuation Coverage Rights

What Is Continuation Coverage?

Federal law requires that most group health plans (including this Plan) give employees and their families the opportunity to continue their healthcare coverage when there is a "qualifying event" that would result in a loss of coverage under an employer's plan.

How Long Will Continuation Coverage Last?

In the case of a loss of coverage due to end of employment or reduction in hours of employment, coverage generally may be continued only for up to a total of 18 months. In the case of losses of coverage due to an employee's death, divorce or legal separation, the employee's becoming entitled to Medicare benefits, or a dependent child ceasing to be a dependent under the terms of the Plan, coverage may be continued for up to a total of 36 months.

How Can You Extend the Length of Continuation Coverage?

If you elect continuation coverage, an extension of the maximum period may be available if a qualified beneficiary is disabled or a second qualifying event occurs. You must notify the Plan Administrator of a disability or a second qualifying event in order to extend the period of continuation coverage.

How Can You Elect Continuation Coverage?

To elect continuation coverage, you must complete the Election Form and furnish it according to the directions on the form. Each qualified beneficiary has a separate right to elect continuation coverage.

How Much Does COBRA Continuation Coverage Cost?

Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage.

When and How Must Payment for COBRA Continuation Coverage be Made?

First payment for continuation coverage. If you elect continuation coverage, you do not have to send any payment with the Election Form.

Periodic payments for continuation coverage. After you make your first payment for continuation coverage, you will be required to pay for continuation coverage for each subsequent coverage period.

Grace periods for periodic payments. Although periodic payments are due on the dates shown above, you will be given a grace period of 30 days to make each periodic payment.

For More Information

This notice does not fully describe continuation coverage or other rights under the Plan. More information about continuation coverage and your rights under the Plan is available in your summary plan description or from the Plan Administrator.

Keep your plan informed of address changes

In order to protect your family's rights, you should keep the Plan Administrator informed of any changes in your address and the addresses of family members.