HR COBRA Rights Document

COBRA RIGHTS AND ELECTION NOTICE

This document provides notification of rights to continue group health plan coverage under the Consolidated Omnibus Budget Reconciliation provisions (commonly referred to as COBRA). Employer and Plan information are provided below, followed by the Qualified Beneficiary's personal data, the qualifying event, an election form, and acknowledgments. Election and premium payment instructions appear in the Election section. This notice contains important deadlines and obligations.

Employer and Plan Information

Qualified Beneficiary — Personal & Employment Information

Employee Name:     Employee ID:

Employment History

Education

References (Professional)

Qualifying Event

Select the qualifying event that entitles the Qualified Beneficiary to elect continuation coverage:

Termination of employment (for reasons other than gross misconduct)

Reduction in hours of employment

Legal separation or divorce of covered employee

Death of covered employee

Loss of dependent status under plan rules

Other qualifying event

Date of Qualifying Event:     Date Coverage Terminated:

COBRA Coverage Options & Premiums

Available coverage options under the plan and monthly premium amounts are listed below. Premiums are payable by the Qualified Beneficiary when COBRA is elected. The initial premium deadline and monthly due dates will be specified by the Plan Administrator.

Single coverage     Family coverage

Important: Qualified Beneficiaries generally have 60 days to elect continuation coverage measured from the later of the date of this notice or the date coverage would otherwise end. If elected, premiums may include a reasonable administrative charge (commonly up to 102% of the applicable premium) and premiums are retroactive to the date coverage was lost. The initial premium payment deadline following an election may be shorter; the Plan Administrator will provide the exact payment deadline. Subsequent premiums are due on a monthly schedule and may include a permitted grace period.

Election To Continue Coverage

Check one option below and sign to elect continuation coverage. If electing, indicate payment method and provide required payment information.

I elect continuation coverage under the plan for the coverage options indicated above.

I decline continuation coverage at this time.

Payroll deduction (if available)

Check or money order

Electronic payment (ACH/credit card)

Termination of Continuation Coverage

Continuation coverage may be terminated earlier than the maximum coverage period for reasons including: nonpayment of required premiums, termination of the employer's plan, a Qualified Beneficiary's entitlement to Medicare after electing COBRA, or fraud or misrepresentation in connection with coverage. The Plan Administrator will notify you of termination reasons and applicable deadlines.

Appeals, Disputes, and Notices

If you dispute a determination regarding eligibility or premiums, submit a written appeal to the Plan Administrator at the address listed above. The Plan Administrator will review appeals in accordance with plan procedures and will provide written notice of any adverse determination with the reasons and any appeal rights.

Legal Disclosures and Acknowledgements

At-Will Employment: Nothing in this notice or the provision of continuation coverage alters the at-will nature of employment where applicable. Employment remains subject to applicable state and federal law.

Equal Opportunity: The Employer is an equal opportunity employer and makes benefits available in a nondiscriminatory manner consistent with applicable law.

Applicant Certification: I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand that providing false information may subject me to penalties as provided by law and plan rules.

Authorization to Contact Previous Employers and Conduct Background Checks: By signing below I authorize the Employer and Plan Administrator to contact prior employers, references, and other entities as reasonably necessary to verify information related to my employment and eligibility for benefits. I further authorize any such parties to provide information requested. I understand this authorization is limited to information necessary to administer benefits or verify eligibility and does not waive privacy protections beyond what is needed for plan administration.

I acknowledge receipt of this COBRA Rights and Election Notice. I understand my rights to elect continuation coverage and the deadlines and payment obligations contained herein.

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