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COBRA Coverage Election Form

(Termination or Reduction in Hours of Employment) Employees who incur a termination of employment or a reduction in hours of employment must be sent a COBRA election form and notice. The basic information in this Form should be included, although employers should modify the information to incorporate their own administrative procedures, different levels of coverage, open enrollment rights, and all other unique features of group health plan coverage applicable to the specific plan. The figures assume that no severance agreement, leave of absence or other agreements have been offered.

Mailed Hand delivered

Date of Notice:


Qualified Beneficiary Information

Name: Last, First, Middle Social Security Number

______________________________________________________________________________________ Home Address Street City State Zip ______________________________________________________________________________________ Date of Birth: __/___/__ No. of Dependent Children: _____ Date of Hire: __/___/__ Marital Status: Single Married

Policy Number: ____________

COBRA Rights Information

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 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. PLEASE NOTE: Continuation coverage under COBRA is provided subject to your eligibility. The Plan Administrator reserves the right to terminate your COBRA coverage retroactively if you are determined to be ineligible for coverage.

Entitlement to COBRA Coverage

If you do not elect COBRA continuation coverage, your coverage under the Plan will end on _______ due to [Check appropriate box]: Termination of employment Reduction in hours of employment

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 18 months [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 A child who is born to or placed for adoption with the covered employee during a period of COBRA coverage will also be eligible to become a qualified beneficiary. In accordance with the terms of the Plan and the requirements of federal law, these qualified beneficiaries can be added to COBRA coverage upon proper notification to the [Indicate either the Plan Administrator or the party responsible for COBRA administration] of the birth or adoption.

COBRA Coverage Options and Costs

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]. You are eligible for (circle one) FAMILY SINGLE coverage. Unless you expressly elect otherwise, this coverage will be continued for you (and your spouse and your dependent child(ren), if any). The regular cost of coverage will be as follows: Family Coverage Single Coverage $ _________ per month $_______ per month 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 separate notice that accompanies this 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].

Instructions for Completing Election Form

To elect COBRA continuation coverage, complete this Election Form and return it to us. Under federal law, you 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 postmarked no later than [Enter date]. If you do not return this completed Election Form to us within 60 days after the date of this notice, you will lose your right to elect COBRA continuation coverage under the Plan. 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 completed Election Form. Read the important information about your rights included in the separate Notice of COBRA


Continuation Coverage Rights accompanying this Election Form.

COBRA Coverage Election Agreement

I (We) have read this Election Form and the accompanying notice of COBRA continuation coverage rights. I (We) understand the rights to elect COBRA continuation coverage and would like to take the action indicated below. I (We) understand that if I (we) elect continuation coverage and fail to pay any premium payment in full and on time, this coverage will terminate. I also agree to notify the Plan Administrator if I or any member of my family become(s) covered under another group health plan or entitled to Medicare after the date of this COBRA election. Please check ONE only. 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:_______________________________] I have read this Election Form and the accompanying Notice of COBRA Continuation Coverage Rights. I am waiving my right to continuation coverage under the Plan. Signature: ______________________________________________________ Date: _____________________ Name (Please Print): __________________________________________________ Relationships to individual(s) listed above: _________________________________ Address: ____________________________________________________________ Telephone: __________________________________________________________ Send form to: Plan Administrator, (ADDRESS). Inquiries should be directed to: Plan Administrator, (TELEPHONE NUMBER).

For Office Use Only

Received by Administrator: _______ Date: ___________




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