Important Information – General Notice
Initial/General Notice of COBRA rights. Continuation coverage rights under COBRA
05/19/2014
Company Name
ABC Test
Contact Name
Mike Smith
Phone
81355512121
Address
1 main st
City, State, Zipcode
Atlanta, New York, 30222
Recipient:
Name of Individual(s)
Employee: Ash
Spouse Name: NG
Dependent: A,A
Address
NY
City, State, Zipcode
NY, New York, 11001
You are receiving this notice because you have recently become covered under a group health plan. This
notice contains important information about your right to COBRA continuation coverage, which is a
temporary extension of coverage under the Plan. This notice generally explains COBRA continuation
coverage, when it may become available to you and your family, and what you need to do to protect
the right to receive it.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you
when you would otherwise lose your group health coverage. It can also become available to other
members of your family who are covered under the Plan when they would otherwise lose their group health
coverage. For additional information about your rights and obligations under the Plan and under federal
law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.
What is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end
because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this
notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a
“qualified beneficiary.” You, your spouse, and your dependent children could become qualified
beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified
beneficiaries who elect COBRA continuation coverage must pay the entire premium amount plus 2% for
COBRA continuation coverage.
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