MODEL COBRA CONTINUATION COVERAGE ELECTION NOTICE (For use by single-employer group health plans) [Enter date of notice]Dear: [Identify the qualified beneficiary(ies), by name or status]This notice contains important information about your right to continue your health care coverage
in the [enter name of group health plan ] (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 [enter date ]
due to [check appropriate box]: End of employment Reduction in hours of employment Death of employee Divorce or legal separation Entitlement to 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 health care coverage under the Plan for up to ___
months [enter 18 or 36, as appropriate and check appropriate box or boxes; names may be added]: Employee or former employee Spouse or former spouse Dependent child(ren) covered under the Plan on the day before the event that caused the loss of
coverage Child who is losing coverage under the Plan because he or she is no longer a dependent under
the Plan If elected, COBRA continuation coverage will begin on [enter date] and can last until [enter date ]. [Add, if appropriate: You may elect any of the following options for COBRA continuation coverage:
[list available coverage options]. COBRA continuation coverage will cost: [enter amount each qualified beneficiary will be required to pay
for each option per month of coverage and any other permitted coverage periods.] 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 [enter name of party responsible for COBRA administration for the Plan, with telephone number
and address].
COBRA CONTINUATION COVERAGE ELECTION FORM I (We) elect COBRA continuation coverage in the [enter name of plan] (the Plan) as indicated below: NameDate of BirthRelationship to Employee SSN (or other identifier) a. _________________________________________________________________________________ [Add if appropriate: Coverage option elected: ] b._________________________________________________________________________________ [Add if appropriate: Coverage option elected: ] c._________________________________________________________________________________ [Add if appropriate: Coverage option elected: ] _____________________________________ _____________________________SignatureDate___________________________________________________________________Print NameRelationship to individual(s) listed above__________________________________________________________________________________________________________________ ______________________________Print AddressTelephone numberINSTRUCTIONS: 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: [Enter Name and Address ]
This Election Form must be completed and returned by mail [or describe other means of
submission and due date]. If mailed, it must be post-marked no later than [enter date].
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.
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 health care coverage when there is a “qualifying event” that would result
in a loss of coverage under an employer’s plan. Depending on the type of qualifying event, “qualified
beneficiaries” can include the employee (or retired employee) covered under the group health plan, the
covered employee’s spouse, and the dependent children of the covered employee.Continuation coverage is the same coverage that the Plan gives to other participants or beneficiaries under
the Plan who are not receiving continuation coverage. Each qualified beneficiary who elects continuation
coverage will have the same rights under the Plan as other participants or beneficiaries covered under the
Plan, including [add if applicable: open enrollment and] special enrollment rights. 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. When the qualifying event is the end of employment or
reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits
less than 18 months before the qualifying event, COBRA continuation coverage for qualified
beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. This
notice shows the maximum period of continuation coverage available to the qualified beneficiaries.Continuation coverage will be terminated before the end of the maximum period if: •any required premium is not paid in full on time,•a qualified beneficiary becomes covered, after electing continuation coverage, under another
group health plan that does not impose any pre-existing condition exclusion for a pre-existing
condition of the qualified beneficiary,• a qualified beneficiary becomes entitled to Medicare benefits (under Part A, Part B, or both) after
electing continuation coverage, or •the employer ceases to provide any group health plan for its employees. Continuation coverage may also be terminated for any reason the Plan would terminate coverage of a
participant or beneficiary not receiving continuation coverage (such as fraud).[If the maximum period shown on page 1 of this notice is less than 36 months, add the following three
paragraphs:]How can you extend the length of COBRA continuation coverage?If you elect continuation coverage, an extension of the maximum period of coverage may be available if a
qualified beneficiary is disabled or a second qualifying event occurs. You must notify [enter name of
party responsible for COBRA administration] of a disability or a second qualifying event in order to
extend the period of continuation coverage. Failure to provide notice of a disability or second qualifying event may affect the right to extend the period of continuation coverage.DisabilityAn 11-month extension of coverage may be available if any of the qualified beneficiaries is determined
by the Social Security Administration (SSA) to be disabled. The disability has to have started at some
time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-
month period of continuation coverage. [Describe Plan provisions for requiring notice of disability
determination, including time frames and procedures.] Each qualified beneficiary who has elected
continuation coverage will be entitled to the 11-month disability extension if one of them qualifies. If the
qualified beneficiary is determined by SSA to no longer be disabled, you must notify the Plan of that fact
within 30 days after SSA’s determination.Second Qualifying EventAn 18-month extension of coverage will be available to spouses and dependent children who elect
continuation coverage if a second qualifying event occurs during the first 18 months of continuation
coverage. The maximum amount of continuation coverage available when a second qualifying event
occurs is 36 months. Such second qualifying events may include the death of a covered employee,
divorce or separation from the covered employee, the covered employee’s becoming entitled to Medicare
benefits (under Part A, Part B, or both), or a dependent child’s ceasing to be eligible for coverage as a
dependent under the Plan. These events can be a second qualifying event only if they would have caused
the qualified beneficiary to lose coverage under the Plan if the first qualifying event had not occurred.
You must notify the Plan within 60 days after a second qualifying event occurs if you want to extend your
continuation coverage.How can you elect COBRA 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. For
example, the employee’s spouse may elect continuation coverage even if the employee does not.
Continuation coverage may be elected for only one, several, or for all dependent children who are
qualified beneficiaries. A parent may elect to continue coverage on behalf of any dependent children.
The employee or the employee's spouse can elect continuation coverage on behalf of all of the qualified
beneficiaries. In considering whether to elect continuation coverage, you should take into account that a failure to
continue your group health coverage will affect your future rights under federal law. First, you can lose
the right to avoid having pre-existing condition exclusions applied to you by other group health plans if
you have more than a 63-day gap in health coverage, and election of continuation coverage may help you
not have such a gap. Second, you will lose the guaranteed right to purchase individual health insurance
policies that do not impose such pre-existing condition exclusions if you do not get continuation coverage
for the maximum time available to you. Finally, you should take into account that you have special
enrollment rights under federal law. You have the right to request special enrollment in another group
health plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer)
within 30 days after your group health coverage ends because of the qualifying event listed above. You
will also have the same special enrollment right at the end of continuation coverage if you get
continuation coverage for the maximum time available to you.
How much does COBRA continuation coverage cost?Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage.
The amount a qualified beneficiary may be required to pay may not exceed 102 percent (or, in the case of
an extension of continuation coverage due to a disability, 150 percent) of the cost to the group health plan
(including both employer and employee contributions) for coverage of a similarly situated plan
participant or beneficiary who is not receiving continuation coverage. The required payment for each
continuation coverage period for each option is described in this notice.[If employees might be eligible for trade adjustment assistance, the following information may be added :
The Trade Act of 2002 created a new tax credit for certain individuals who become eligible for trade
adjustment assistance and for certain retired employees who are receiving pension payments from the
Pension Benefit Guaranty Corporation (PBGC) (eligible individuals). Under the new tax provisions,
eligible individuals can either take a tax credit or get advance payment of 65% of premiums paid for
qualified health insurance, including continuation coverage. If you have questions about these new tax
provisions, you may call the Health Coverage Tax Credit Customer Contact Center toll-free at 1-866-628-
4282. TTD/TTY callers may call toll-free at 1-866-626-4282. More information about the Trade Act is
also available at www.doleta.gov/tradeact/2002act_index.asp.When and how must payment for COBRA continuation coverage be made?First payment for continuation coverageIf you elect continuation coverage, you do not have to send any payment with the Election Form.
However, you must make your first payment for continuation coverage not later than 45 days after the
date of your election. (This is the date the Election Notice is post-marked, if mailed.) If you do not make
your first payment for continuation coverage in full not later than 45 days after the date of your election,
you will lose all continuation coverage rights under the Plan. You are responsible for making sure that
the amount of your first payment is correct. You may contact [enter appropriate contact information,
e.g., the Plan Administrator or other party responsible for COBRA administration under the Plan ] to
confirm the correct amount of your first payment.Periodic payments for continuation coverageAfter you make your first payment for continuation coverage, you will be required to make periodic
payments for each subsequent coverage period. The amount due for each coverage period for each
qualified beneficiary is shown in this notice. The periodic payments can be made on a monthly basis.
Under the Plan, each of these periodic payments for continuation coverage is due on the [ enter due day
for each monthly payment] for that coverage period. [If Plan offers other payment schedules, enter with
appropriate dates: You may instead make payments for continuation coverage for the following
coverage periods, due on the following dates:]. If you make a periodic payment on or before the first day
of the coverage period to which it applies, your coverage under the Plan will continue for that coverage
period without any break. The Plan [select one: will or will not] send periodic notices of payments due
for these coverage periods. Grace periods for periodic paymentsAlthough periodic payments are due on the dates shown above, you will be given a grace period of 30
days after the first day of the coverage period [or enter longer period permitted by Plan] to make each
periodic payment. Your continuation coverage will be provided for each coverage period as long as
payment for that coverage period is made before the end of the grace period for that payment. [If Plan
suspends coverage during grace period for nonpayment, enter and modify as necessary: However, if you
pay a periodic payment later than the first day of the coverage period to which it applies, but before the
end of the grace period for the coverage period, your coverage under the Plan will be suspended as of the
first day of the coverage period and then retroactively reinstated (going back to the first day of the
coverage period) when the periodic payment is received. This means that any claim you submit for
benefits while your coverage is suspended may be denied and may have to be resubmitted once your
coverage is reinstated.]If you fail to make a periodic payment before the end of the grace period for that coverage period, you
will lose all rights to continuation coverage under the Plan.Your first payment and all periodic payments for continuation coverage should be sent to:[enter appropriate payment address]For more informationThis 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. If you have any questions concerning the information in this notice, your rights to coverage, or if you
want a copy of your summary plan description, you should contact [enter name of party responsible for
COBRA administration for the Plan, with telephone number and address].For more information about your rights under ERISA, including COBRA, the Health Insurance
Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the U.S.
Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the
EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA
Offices are available through EBSA’s website.)
Keep Your Plan Informed of Address ChangesIn order to protect your and your family’s rights, you should keep the Plan Administrator informed of any
changes in your address and the addresses of family members. You should also keep a copy, for your
records, of any notices you send to the Plan Administrator.
Practical advice on preparing your ‘Cobra Sample Letter’ online
Are you fed up with the inconvenience of managing paperwork? Look no further than airSlate SignNow, the leading eSignature solution for individuals and small to medium-sized businesses. Bid farewell to the monotonous cycle of printing and scanning documents. With airSlate SignNow, you can effortlessly complete and sign documents online. Utilize the robust features embedded in this intuitive and cost-effective platform and transform your methodology toward document management. Whether you require form approval or signature collection, airSlate SignNow manages it all efficiently, with just a few clicks.
Follow this step-by-step tutorial:
- Log into your account or register for a complimentary trial with our service.
- Click +Create to upload a file from your device, cloud storage, or our form library.
- Open your ‘Cobra Sample Letter’ in the editor.
- Click Me (Fill Out Now) to complete the form on your end.
- Add and assign fillable fields for others (if necessary).
- Proceed with the Send Invite options to request eSignatures from others.
- Save, print your copy, or convert it into a reusable template.
No need to worry if you need to collaborate with your colleagues on your Cobra Sample Letter or send it for notarization—our platform provides all the tools you need to accomplish these tasks. Register with airSlate SignNow today and elevate your document management to a new level!