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P ? PREMIUM CALCULATION AND PAYMENT <br />You and your dependents, if any, are eligible for the following continuation <br />coverage(s). Please check the coverages that you want to continue and then total <br />the monthly premium for those checked. <br />Monthly Premium <br />S <br />S <br />S <br />S <br />S <br />S <br />Total Monthly Premium: S <br />It is your responsibility to pay the above Total Monthly Premium each month by <br />check or money order made payable to City of Mounds View and send to Finance <br />monrnry payments are subject to change only once a year based on a fixed <br />determination period. These changes will usually correspond with premium changes <br />for employees or dependents covered for identical benefits under the plan with <br />respect to whom a qualifying event has not occurred. Your benefits will be the <br />sane as those for persons covered through regular employment, and may change from <br />time to time by plan amendments. <br />It is suggested that you submit with this form the full premium for the period <br />from the date coverage would otherwise end through the current month. However: <br />1. You may defer premium payment foe 45 days following the date you <br />send this completed election form to the office shown above. <br />Such deferred payments should include premium for the period from <br />the date coverage would otherwise end through the current month. <br />2. Premium payments for subsequent months of continued coverage must <br />be paid not layer than (a) the plan's normal gra,.e period, or (b) <br />30 days, whichever is greater, after the first day of such months. <br />FAILURE. TO PAY PREMIUMS WITHIN THE ABOVE —DESCRIBED TIME CONSTRAINTS WILL RESULT <br />IN A LOSS OF CONTINUATION OOVERAGE. THERE IS W RErNSTATDRW. <br />-3- Form COBRA-2 <br />