Agenda Packets - 1988/01/25 - Laserfiche WebLink

Home Browse Search

WrICE TO PERSONS 53106E GAWP HEALTH BENEFITS ARE TEMB ATING Group Plan Account No. / Member's Identification No. Tlx: Wce: RE: Notice of Right to Contribute Group Health Coverage Your group health coverage has ended due to the following "qualifying event" (check one) ❑ Termination of the employee's []For a spouse and eligible dependents, employment (other than for gross loss of coverage due to the employee misconduct) or reduction of hours becoming eligible for Medicare; worked which renders the employee ineligible for coverage; ❑ Death of employee; ❑ For a dependent child, ceasing to qualify as a dependent under the ❑ Divorce or legal separation plan. Date of "qualifying event" Your group health coverage would normally terminate as of Under Federal law however, if your group health benefits end due to a "qualifying• event", you may elect to continue you. ,.verage, at your expense, under the plan. CONTINUATION PERIOD `= If elected, -overage will end on the earliest of the following: A) 18 months after the date of termina- D) For each continued arson, the date tion of your employment (other than that person becomes covered under for gross misconduct) or reduction another group health plan or under of hours worked which renders you Medicare: or - ineligible for coverage; or B) 18 months after the date of termina- E) The end of the last premium period tion of employment (other than for for which payment is made on a gross misconduct) or reduction of timely basis; or hours worked by an employee which renders you, as a dependent of the F) The date the employer ceases to employee, ineligible for coverage; or provide any group health plan to any employee. C) 36 months after the date of any other qualifying event; EXTENDED OCNIINWTION PERIOD If your coverage is continued as a dependent in accordance with Item (B) under Continuation Period above and if during that 18 month continuation period: 1. The employee dies or becomes covered under Medicare; or 2. The employee and spouse are divorced or legally eparated; or 3. You cease to be a dependent child as defined by the plan; you may qualify for extended continuation. The extended period will be 36 months, counting from the date your original 18 month period began. Request for extended continuation must be sent to the undersigned employer within 60 days after the occurrence of any above -described qualifying events or you will not receive extended continuation coverage. Form COBRA-2