COBRA CONTINUATION COVERAGE — ELECTION NOTICE AND FORM

Date of Notice: [__/__/____]

Plan Name: [________________________________]

Plan Number: [____]

TABLE OF CONTENTS

1. Important Information About COBRA Rights
2. Plan Administrator Contact Information
3. Qualifying Event Information
4. Qualified Beneficiaries
5. Available Coverage and Premiums
6. Election Period and Deadlines
7. Premium Payment Information
8. Duration of COBRA Coverage
9. Special Enrollment Rights
10. COBRA Election Form

IMPORTANT INFORMATION ABOUT YOUR COBRA CONTINUATION COVERAGE RIGHTS {#important-information}

PLEASE READ THIS NOTICE CAREFULLY. IT CONTAINS IMPORTANT INFORMATION ABOUT YOUR RIGHT TO CONTINUE YOUR HEALTH CARE COVERAGE.

You are receiving this notice because a qualifying event has occurred that may result in the loss of your coverage under the group health plan named above. You may be entitled to elect COBRA continuation coverage under federal law. This notice describes your rights and obligations under COBRA.

PLAN ADMINISTRATOR CONTACT INFORMATION {#plan-administrator}

The party responsible for administering COBRA continuation coverage under this plan is:

Plan Administrator:

Name: [________________________________]

Company: [________________________________]

Address: [________________________________]

City, State, ZIP: [________________________________]

Phone: [________________________________]

Email: [________________________________]

COBRA Administrator (if different):

Name: [________________________________]

Phone: [________________________________]

Website: [________________________________]

QUALIFYING EVENT INFORMATION {#qualifying-event}

Qualifying Event: (check applicable event)

☐ Termination of employment (other than for gross misconduct)
☐ Reduction in hours of employment
☐ Death of covered employee
☐ Divorce or legal separation from covered employee
☐ Covered employee becoming entitled to Medicare
☐ Dependent child ceasing to qualify as a dependent under plan terms

Date of Qualifying Event: [__/__/____]

Date Coverage Will End (Without COBRA Election): [__/__/____]

QUALIFIED BENEFICIARIES {#qualified-beneficiaries}

The following individuals are qualified beneficiaries entitled to elect COBRA continuation coverage:

Each qualified beneficiary listed above has an independent right to elect COBRA coverage. Covered employees may elect COBRA on behalf of their spouses, and parents may elect COBRA on behalf of their minor children.

AVAILABLE COVERAGE AND PREMIUMS {#available-coverage}

You may elect to continue any of the group health plan coverages you had on the day before the qualifying event:

ELECTION PERIOD AND DEADLINES {#election-period}

You have 60 days to elect COBRA continuation coverage.

Your 60-day election period begins on the later of:
- The date of the qualifying event: [__/__/____]; or
- The date of this notice: [__/__/____]

Your election must be postmarked or received no later than: [__/__/____]

If you do not elect COBRA within this 60-day period, you will lose your right to elect COBRA continuation coverage. Your election is retroactive to the date coverage would have otherwise been lost.

PREMIUM PAYMENT INFORMATION {#premium-payment}

7.1 Your first premium payment is due within 45 days after the date you elect COBRA.

7.2 Subsequent premium payments are due on the first of each month, with a 30-day grace period.

7.3 Payment Methods:

☐ Check payable to [________________________________]
☐ Online payment at [________________________________]
☐ Automatic bank draft

7.4 Mail payments to: [________________________________]

7.5 IMPORTANT: If you fail to make a timely premium payment, your COBRA coverage will be terminated retroactively to the last day for which timely payment was made.

DURATION OF COBRA COVERAGE {#duration}

8.1 Maximum Coverage Period:

☐ 18 months — For termination of employment or reduction in hours
☐ 29 months — If a qualified beneficiary is determined disabled by Social Security within the first 60 days of COBRA (11-month extension)
☐ 36 months — For divorce/legal separation, death of employee, Medicare entitlement, or loss of dependent status

8.2 COBRA coverage may end before the maximum period if:

☐ The premium is not paid on time
☐ The employer ceases to maintain any group health plan
☐ The qualified beneficiary becomes covered under another group health plan (without a preexisting condition limitation)
☐ The qualified beneficiary becomes entitled to Medicare
☐ The qualified beneficiary engages in conduct that would justify termination of a similarly situated active employee's coverage

SPECIAL ENROLLMENT RIGHTS {#special-enrollment}

9.1 Instead of or in addition to COBRA, you may have special enrollment rights under HIPAA in a spouse's employer group health plan if you request enrollment within 30 days of losing coverage.

9.2 You may also be eligible for coverage through the Health Insurance Marketplace. Open enrollment and special enrollment periods may apply. Visit www.healthcare.gov for more information.

COBRA ELECTION FORM {#election-form}

INSTRUCTIONS: Complete and return this form to the Plan Administrator at the address above by [__/__/____].

I. Qualified Beneficiary Making Election:

Name: [________________________________]

Address: [________________________________]

City, State, ZIP: [________________________________]

Phone: [________________________________] Email: [________________________________]

II. Election (check one):

☐ I ELECT COBRA continuation coverage for the following coverages and individuals:

☐ I WAIVE COBRA continuation coverage. I understand that by waiving COBRA I may revoke this waiver at any time before the end of the election period and elect COBRA retroactively.

III. Signature:

Signature: [________________________________] Date: [__/__/____]

Printed Name: [________________________________]

Sources and References

• 29 U.S.C. § 1166 — COBRA Notice Requirements
• 29 CFR § 2590.606-4 — COBRA Election Notice
• DOL — COBRA Continuation Coverage
• 26 CFR § 54.4980B — COBRA Tax Regulations