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NOTICE TO EMPLOYER OF QUALIFYING EVENT <br />'" Date: <br />City of Mounds View <br />TO: 2401 Highway 10 FROM: <br />Mounds View, MN 55112 <br />Employee, Spouse or <br />Dependent Name and <br />Address <br />Employee name: <br />Effective on , one of the following <br />"qualifying events" occurred that could entitle me, my <br />dependents or my spouse to continuation of health <br />benefits (check one): <br />❑ Divorce or legal separation between the employee <br />and spouse. <br />❑ Spouse and/or eligible dependents have lost <br />coverage due to the employee beneficiary eligible <br />for Medicare. <br />' ❑ A dependent child has lost coverage due to child <br />ceasing to qualify as a dependent under the plan. <br />Names of persons affected by the "qualifying event" and <br />their relation to the employee: <br />NAME RELATION <br />(Use separate sheet for additional <br />names) <br />Please send me the corresponding election forms. I under- <br />stand that notification must be made to the employer with <br />in 60 days of the date of a "qualifying event." I hereby <br />certify that the above information is true and correct to <br />the best of my knowledge. <br />nature Date <br />PLEASF INCLUDE EVIDENCE OF QUALIFYING EVENT, SUCH AS <br />COPIES OF DIVORCE.' DECREES, DEPENDENT BIRTH CERTIFICATE, <br />ETC. <br />Form COBRA-4 <br />