COBRA Election Notice

Date:

To:

From:

Introduction

This notice contains important information about your right to continue your group health coverage through COBRA under the group health plan. Please read the information carefully.

Qualifying Event

You have experienced the following qualifying event:

• Qualifying Event:
• Date of Qualifying Event:
• Coverage Loss Date:

Coverage Options

Under COBRA, you may elect to continue the following benefits:

Plan Name	Coverage Level	Monthly Premium

Election Period

You have 60 days from the date of this notice to elect COBRA continuation coverage. Failure to elect within this time frame will result in loss of your right to continue coverage.

How to Elect

To elect COBRA coverage, please complete the enclosed election form and return it to us at:

Payment Information

• Monthly Premium Amount:
• First Payment Due Date:
• Subsequent Payment Due Dates:
• Where to Send Payment:

Coverage Period

Your COBRA continuation coverage begins on the date your group health coverage would otherwise end and can last as long as:

• Maximum COBRA Coverage Period:

Additional Information

• Contact for Questions:
• Phone:
• Email: