**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:

Name Date of Birth Relationship to Employee SSN (or other identifier)

a\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\[*Add if appropriate:* Coverage option elected:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\]

b\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\[*Add if appropriate:* Coverage option elected:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\]

c\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\[*Add if appropriate:* Coverage option elected:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\]

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature Date

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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
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.

## 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. \[*Describe Plan provisions for requiring notice of disability
determination, including time frames and procedures.*\] 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 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 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.cfm](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 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 coverage*

After 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 payments*

Although 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 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 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](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 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.