KEYWORD:

EMPLOYEE BENEFITS MEMORANDUM

DATE:	July 1, 1999
RE:	Sample COBRA Notice

NOTICE TO PERSONS WHOSE GROUP HEALTH AND DENTAL
BENEFITS ARE TERMINATING

PERSONS ELIGIBLE FOR CONTINUED COVERAGE

Dates of Birth

Associate:       ____________________ _______________________

Dependent(s): ____________________ _______________________

                      ____________________ _______________________

                      ____________________ _______________________

                      ____________________ _______________________

Under Federal Law, if you are covered under (Your employer's) group health care plan and your group insurance benefits end because of a "qualifying event," you may elect to continue coverage under the plan.

A "qualifying event" is any of the following:

For an associate, the associate's spouse, and eligible dependents:

the termination of the associate's employment with (Employer) (for reasons other than gross misconduct) or reduction of hours worked so as to render the associate ineligible for coverage; or
the last day of the associate's leave under the Family and Medical Leave Act (FMLA), if the associate has informed (Employer) that he or she does not plan to return to work once the applicable FMLA leave period has expired.

For an associate's spouse and eligible dependents:

death of the associate;
divorce or legal separation from the associate; or
loss of coverage because of an associate's entitlement to Medicare.

For a dependent child:

ceasing to qualify as a dependent under the plan.

If elected, the continued coverage will end without notice on the earliest of the following:

18 months after the date of termination of employment or reduction of hours;
29 months if the terminated associate or a covered family member of the associate is disabled for Social Security purposes within 60 days of the qualifying event. However, if the disabled associate receives a final determination that he or she is no longer disabled, coverage will end on the first day of the month that is 30 days after the final determination (but not earlier than 18 months after the qualifying event). (Note: Months 19-29 are considered your "disability extension period". Your premiums may increase during this period);
36 months after the date of any qualifying event other than termination of employment or reduction in hours;
The date that (Employer) ceases to provide any group health plan to any associate;
The date the associate or dependent(s) fails to make any required premium payment when due;
The date the associate or dependent becomes:
1. covered under any other group plan; or
2. entitled to Medicare.
If an associate becomes entitled to Medicare before experiencing a termination of employment or reduction of hours of employment, the maximum coverage period for qualified beneficiaries (other than the associate) ends on the later of:
1. 36 months after the date the associate became entitled to Medicare benefits; or
2. 18 months (or 29 months, if there is a disability extension) after the date of the associate's termination of employment or reduction of hours of employment.

Your qualifying event occurred on ____________________

To continue your coverage, you should return this form to (Plan Administrator) along with your application and first premium payment payable to as soon as possible. Subsequent premiums must be received by no later than the ______ day of each month in order to continue your coverage through the following month. Failure to submit this form by___________ will result in your coverage being terminated as of the date of your qualifying event.

The premium for family coverage under the health care plan is ___________ and the premium for family coverage under the dental plan is _________. The premium for coverage for associate plus one under the health care plan is ____________ and the premium for associate plus one under the dental care plan is _____________. The premium for coverage for an associate only under the health care plan is ____________ and the premium for coverage for an associate only under the dental care plan is _______________. To continue your coverage you must submit the appropriate premium for each person for which continued coverage is desired.

This form must be signed below. If this form has been sent to the Associate and his/her spouse, both must sign below. Make your check payable to ___________and indicate in the memo area the coverage (Medical or Dental or both) that you are continuing.

(Your insurance provider) will bill you appropriately each month for the coverage you elect to continue.

___________________________
Signature of Former Associate ___________________________
Signature of Spouse

___________________________
Date ___________________________
Date

Please return the COBRA application, your check to cover the first initial monthly premium and copies of pages 3 and 4 of this document to your local HR representative at the address listed below:

(Name & address of local HR representative)

You should retain a copy of this COBRA application for your records.

If you have any questions, please do not hesitate to call (Your Plan Administrator).

I(we), the undersigned, have read the above and hereby make election as indicated below:

Health Care Plan Coverage:

[ ] Continuation coverage is declined
[ ] Continuation is elected by the following individuals only:

Signature Social Security Number

____________________ ____________________(associate)

____________________ ____________________(spouse)

____________________ ____________________(dependent)

____________________ ____________________(dependent)

____________________ ____________________(dependent)

Dental Care Plan Coverage:

[ ] Continuation coverage is declined
[ ] Continuation coverage is elected by the following individuals only: