Healthcare COBRA Rights Notice

HEALTHCARE COBRA RIGHTS NOTICE

Plan and Employer Information

Participant / Beneficiary Information

Date of Birth:    Gender:

Phone:    Email:

Qualifying Event Details

Qualifying event (check all that apply):

Termination of employment (for reasons other than gross misconduct)

Reduction in hours of employment

Death of the employee

Divorce or legal separation from the employee

Loss of dependent status under the plan

Employee entitlement to Medicare

Date of Qualifying Event:    Date Coverage Lost or Will Be Lost:

Statement of Rights and Election Procedures

This notice describes rights to elect continuation of group health coverage (COBRA) under the terms of the plan. Under the terms of the plan and applicable law, you and other qualified beneficiaries have the right to elect continuation coverage for a limited period following the qualifying event identified above. The plan will offer the same coverage that was in effect immediately before the qualifying event subject to plan terms, exclusions and limitations.

Election Period: You have a limited election period to elect COBRA continuation coverage. The election period runs for 60 days from the later of (1) the date you would lose coverage due to the qualifying event or (2) the date you receive this notice. Election must be made within that 60-day period. Election Deadline (for plan use or beneficiary calculation):

If you elect continuation coverage, coverage will be effective retroactive to the date coverage would otherwise have ended, provided timely payment of premiums is made. If you do not elect continuation coverage within the election period, you will forfeit the right to elect continuation coverage under this notice.

Premiums, Duration, and Payment Terms

Monthly premium amount (current): $    Initial premium due date:

Period of coverage if elected: months, subject to earlier termination for nonpayment of premiums, termination of the plan, or other reasons permitted by the plan and applicable law.

Payment instructions: Premiums must be paid in full and timely to the plan or plan administrator at the address specified above or to another address designated by the plan administrator in writing. Late payment or failure to timely pay the premium will result in loss of continuation coverage. The plan may impose a reasonable grace period for subsequent monthly payments consistent with plan terms.

Special Circumstances and Extensions

Disability extension: If a qualified beneficiary is determined disabled under the Social Security Act within the first 60 days of COBRA coverage, an extension of coverage for up to an additional 11 months (for a total of 29 months) may be available. Evidence of disability must be provided to the plan administrator in writing within the time period required by the plan. Disability determination received by:

Second qualifying event: If a second qualifying event occurs during the initial 18- or 36-month period and notification and proof are provided within the required timeframes, the maximum period of continuation coverage may be extended for dependents. Notice of a second qualifying event must be provided to the plan administrator within the time period required by the plan.

Obligations of the Participant / Beneficiary

It is the responsibility of the participant or beneficiary to notify the plan administrator promptly of any change of address or any event that may affect eligibility, and to provide any requested documentation substantiating entitlement to continuation coverage. Current mailing address (for notices and premium billing):

Election of Continuation Coverage

Election: I have been informed of my COBRA rights and choose the option below. I understand that this election will be effective only if made within the election period and accompanied by any required initial premium payment.

I elect COBRA continuation coverage for myself and eligible dependents as noted below.

I decline COBRA continuation coverage. I understand that by declining I forfeit the right to elect continuation coverage for this qualifying event.

Privacy and Record Acknowledgment

The plan will use the information you provide for administration of continuation coverage. By signing below you acknowledge receipt of this COBRA Rights Notice and confirm that the information provided is true and accurate to the best of your knowledge.

Additional Remarks / Documentation

I certify that I have received adequate notice of my rights to continuation coverage and understand the procedures, deadlines, and payment obligations described herein. I understand that failure to timely elect continuation coverage or to timely pay premiums will result in termination of rights to continued coverage under the plan.

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