**Model General Notice Of COBRA Continuation Coverage Rights**

**(For use by single-employer group health plans)**

**\*\* Continuation Coverage Rights Under COBRA\*\***

**Introduction**

You are receiving this notice because you have recently become covered
under a group health plan (the Plan). This notice contains important
information about your right to COBRA continuation coverage, which is a
temporary extension of coverage under the Plan. **This notice generally
explains COBRA continuation coverage, when it may become available to
you and your family, and what you need to do to protect the right to
receive it.**

The right to COBRA continuation coverage was created by a federal law,
the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
COBRA continuation coverage can become available to you when you would
otherwise lose your group health coverage. It can also become available
to other members of your family who are covered under the Plan when they
would otherwise lose their group health coverage. For additional
information about your rights and obligations under the Plan and under
federal law, you should review the Plan's Summary Plan Description or
contact the Plan Administrator.

# What is COBRA Continuation Coverage?

COBRA continuation coverage is a continuation of Plan coverage when
coverage would otherwise end because of a life event known as a
"qualifying event." Specific qualifying events are listed later in this
notice. After a qualifying event, COBRA continuation coverage must be
offered to each person who is a "qualified beneficiary." You, your
spouse, and your dependent children could become qualified beneficiaries
if coverage under the Plan is lost because of the qualifying event.
Under the Plan, qualified beneficiaries who elect COBRA continuation
coverage \[*choose and enter appropriate information:* must pay *or* are
not required to pay\] for COBRA continuation coverage.

If you are an employee, you will become a qualified beneficiary if you
lose your coverage under the Plan because either one of the following
qualifying events happens:

-   Your hours of employment are reduced, or

-   Your employment ends for any reason other than your gross
    misconduct.

If you are the spouse of an employee, you will become a qualified
beneficiary if you lose your coverage under the Plan because any of the
following qualifying events happens:

-   Your spouse dies;

-   Your spouse's hours of employment are reduced;

-   Your spouse's employment ends for any reason other than his or her
    gross misconduct;

-   Your spouse becomes entitled to Medicare benefits (under Part A,
    Part B, or both); or

-   You become divorced or legally separated from your spouse.

> Your dependent children will become qualified beneficiaries if they
> lose coverage under the Plan because any of the following qualifying
> events happens:

-   The parent-employee dies;

-   The parent-employee's hours of employment are reduced;

-   The parent-employee's employment ends for any reason other than his
    or her gross misconduct;

-   The parent-employee becomes entitled to Medicare benefits (Part A,
    Part B, or both);

-   The parents become divorced or legally separated; or

-   The child stops being eligible for coverage under the plan as a
    "dependent child."

**When is COBRA Coverage Available?**

The Plan will offer COBRA continuation coverage to qualified
beneficiaries only after the Plan Administrator has been notified that a
qualifying event has occurred. When the qualifying event is the end of
employment or reduction of hours of employment, death of the employee,
\[*add if Plan provides retiree health coverage:* commencement of a
proceeding in bankruptcy with respect to the employer,\] or the
employee\'s becoming entitled to Medicare benefits (under Part A, Part
B, or both), the employer must notify the Plan Administrator of the
qualifying event.

**You Must Give Notice of Some Qualifying Events**

**For the other qualifying events (divorce or legal separation of the
employee and spouse or a dependent child's losing eligibility for
coverage as a dependent child), you must notify the Plan Administrator
within 60 days \[*or enter longer period permitted under the terms of
the Plan*\] after the qualifying event occurs. You must provide this
notice to: \[*Enter name of appropriate party*\]. \[*Add description of
any additional Plan procedures for this notice, including a description
of any required information or documentation.*\]**

**How is COBRA Coverage Provided?**

Once the Plan Administrator receives notice that a qualifying event has
occurred, COBRA continuation coverage will be offered to each of the
qualified beneficiaries. Each qualified beneficiary will have an
independent right to elect COBRA continuation coverage. Covered
employees may elect COBRA continuation coverage on behalf of their
spouses, and parents may elect COBRA continuation coverage on behalf of
their children.

COBRA continuation coverage is a temporary continuation of coverage.
When the qualifying event is the death of the employee, the employee\'s
becoming entitled to Medicare benefits (under Part A, Part B, or both),
your divorce or legal separation, or a dependent child\'s losing
eligibility as a dependent child, COBRA continuation coverage lasts 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. For example, if a covered employee becomes
entitled to Medicare 8 months before the date on which his employment
terminates, COBRA continuation coverage for his spouse and children can
last up to 36 months after the date of Medicare entitlement, which is
equal to 28 months after the date of the qualifying event (36 months
minus 8 months). Otherwise, when the qualifying event is the end of
employment or reduction of the employee's hours of employment, COBRA
continuation coverage generally lasts for only up to a total of 18
months. There are two ways in which this 18-month period of COBRA
continuation coverage can be extended.

***Disability extension of 18-month period of continuation coverage***

If you or anyone in your family covered under the Plan is determined by
the Social Security Administration to be disabled and you notify the
Plan Administrator in a timely fashion, you and your entire family may
be entitled to receive up to an additional 11 months of COBRA
continuation coverage, for a total maximum of 29 months. The disability
would have 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. \[*Add description of any
additional Plan procedures for this notice, including a description of
any required information or documentation, the name of the appropriate
party to whom notice must be sent, and the time period for giving
notice.*\]

***Second qualifying event extension of 18-month period of continuation
coverage***

If your family experiences another qualifying event while receiving 18
months of COBRA continuation coverage, the spouse and dependent children
in your family can get up to 18 additional months of COBRA continuation
coverage, for a maximum of 36 months, if notice of the second qualifying
event is properly given to the Plan. This extension may be available to
the spouse and any dependent children receiving continuation coverage if
the employee or former employee dies, becomes entitled to Medicare
benefits (under Part A, Part B, or both), or gets divorced or legally
separated, or if the dependent child stops being eligible under the Plan
as a dependent child, but only if the event would have caused the spouse
or dependent child to lose coverage under the Plan had the first
qualifying event not occurred.

**If You Have Questions**

Questions concerning your Plan or your COBRA continuation coverage
rights should be addressed to the contact or contacts identified below.
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 nearest Regional or
District Office of 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 Changes**

In order to protect your family's rights, you should keep the Plan
Administrator informed of any changes in the addresses of family
members. You should also keep a copy, for your records, of any notices
you send to the Plan Administrator.

**Plan Contact Information**

\[*Enter name of group health plan and name (or position), address and
phone number of party or parties from whom information about the plan
and COBRA continuation coverage can be obtained on request.*\]