Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event while receiving 18 months of COBRA continuation
coverage, the spouse and dependent children in your family can get up to 18 additional months of
COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is
properly given to the Plan. This extension may be available to the spouse and any dependent children
receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare
benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child
stops being eligible under the Plan as a dependent child, but only if the event would have caused the
spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.
If You Have Questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to
the contact or contacts identified below. For more information about your rights under ERISA, including
COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting
group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s
Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at
www.dol.gov/ebsa.
Plan Contact Information
Company Name
Contact Name
Mike Smith
Phone
81355512121
Address
1 main st
City, State, Zipcode
5 of 5
ABC Test
Atlanta, New York, 30222