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COBRA Continuation Coverage Election Notice (For use by single-employer group health plans){Date of Notice} Dear {Insert Name}: 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 C OBRA continuation coverage, follow the instructions on the next page to complete the enclose d 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 Enrollment in Medicare Loss of dependent child status Each person ("qualified beneficiary") in the category(ies) checked below is entitled t o elect COBRA continuation coverage, which will continue group healthcare 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 {Name may be added here} Spouse or former spouse {Name may be added here} Dependent child(ren) covered under the Plan on the day before the event that the loss of coverage {Name may be added here} Child who is losing coverage under the Plan because he or she is no longer dependent under the Plan {Name may be added here} 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 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:{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 competed Election Form. Read the important information about your rights included in the pages after the Elec tion Form. I (We) elect COBRA continuation coverage in [enter name of plan] (the Plan) as indicated below: I (We) elect to continue our coverage in the [enter name of plan] (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] Name: Date of Birth: Relationship to Employee: SSN (or other identifier): Coverage option elected: [Add if appropriate] Signature: ____________________________________________________________________ Print Name: Relationship to individual(s) listed above: Print Address: Telephone Number: 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. 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 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 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 preexisting 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 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 {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. Disability An 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, inlcuding 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 Event An 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 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 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 preexisting 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 percent of premiums paid for qualified health insurance, including continuation coverage. If you have questions about these new tax provisions, you may call the Health Care Tax Credit Customer Contact Center toll-free at 866-628-4282. TTD/TTY callers may call toll-free at 866-626-4282. Further information about the Trade Act is also available at: http:// www.doleta.gov/tradeact/2002act_index.cfm. 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. However, you must make your first payment for continuation coverage no 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 no 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 for the party responsible for COBRA administration under the Plan} to confirm the correct amount of your first payment. 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. 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 date for each monthly payment}for that coverage period. [If Plan offers other payment schedules, enter the following 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 [will or will not] send periodic notices of payments due for these coverage periods. 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 [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 for 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 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. If you have 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 http://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 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. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.