Welcome to CobraServ. Managed business solutions for human resources and employee effectiveness

Welcome to CobraServ Managed business solutions for human resources and employee effectiveness

Managed business solutions for human resources and employee effectiveness WELCOME TO CobraServ Dear CobraServ Customer: Welcome to CobraServ - the nation s largest COBRA compliance service. We look forward to providing you with the best COBRA compliance administration available, to minimize your involvement in COBRA. Members of our implementation team will be contacting you. They will review the materials in this section ("Welcome to CobraServ") and the section entitled "CobraServ Forms" and discuss how CobraServ can best meet your needs. Our team will show you just how well they know COBRA and will share their knowledge with you. CobraServ does it all, from assuming administration of your COBRA continuants, to performing future billing and adjudication of eligibility, to collecting and processing all related transactions. With CobraServ, your role is reduced to responding to 3 situations: 1 When individuals first become covered under your plan; 2 When an individual experiences a COBRA Qualifying Event; 3 If you receive a report of COBRA activity that requires response. In this document, you will find information concerning: What CobraServ Does What the Employer Does Reports and Updating Your Carrier COBRA Compliance Requirements

Managed business solutions for human resources and employee effectiveness WHAT CobraServ DOES Elections, Billing, Reporting, Additional Services Elections CobraServ Customer Service Representatives (CSRs) respond to all inquiries from Qualified Beneficiaries. CobraServ provides a toll-free hotline to continuants 24 hours-a-day, 365 days a year for premium inquiries through our Interactive Voice Response (IVR) system. Qualified Beneficiaries can elect COBRA by phone via the IVR system; on our Website using Elect By Net; or on paper with a COBRA Election Form. CobraServ determines whether the elections CobraServ receives were made within the allowable 60-day period. CobraServ offers special status reports to employers. We provide an employer a toll-free hotline to call for assistance. Billing CobraServ administers the initial 45-day and ongoing 30-day grace periods. Each month, CobraServ sends each continuant a detailed bill with a payment envelope and a request for ongoing certification of continuant eligibility. CobraServ sends grace letters to those who don t pay within eight days of the grace expiration date. CobraServ determines any late payments. We accept full and partial premium payments, within Safe Harbor. Checks are returned that are non-negotiable (no signature, wrong payee, etc.) if they are received by CobraServ more than 10 days before the grace period expiration date. Checks received less than 10 days before the grace period expiration date are also returned, and the COBRA continuant is given up to 10-days to correct their non-negotiable check. CobraServ follows up on dishonored checks. CobraServ archives critical documents and materials for seven years in a professional archiving facility, to resolve potential disputes. CobraServ sends cancellation notices to those who do not pay their premiums within the grace period. If you have active continuants, you will receive a monthly consolidated premium check representing premiums collected from COBRA continuants, less the 2% administrative fee paid by the continuant. Accompanying reports will indicate actions to be taken, if any.

WHAT CobraServ DOES (continued) Elections, Billing, Reporting, Additional Services Additional Services CobraServ also provides the following additional services: employs two different ERISA law firms to help keep your plan in compliance and to stay up-to-date on court cases affecting COBRA. CobraServ forms are updated as the regulations change; utilizes a Research Department to stay current on compliance changes and trends through subscriptions to industry publications, legislative bulletins and legal update services; sends conversion notices, where appropriate, in the last 90 days before COBRA reaches maximum term; accepts calls from providers, hospital representatives, agents, brokers or HMOs regarding coverages/ eligibility; provides employer with mail labels for all COBRA continuants to assist in Open Enrollment communications; handles multiple Qualifying Events (for example, termination of employment followed by divorce); provides ongoing customer service to all administrators and continuants.

Managed business solutions for human resources and employee effectiveness Initial Notice of COBRA Rights OVERVIEW OF EMPLOYER RESPONSIBILITIES Whenever a new employee or a spouse or a dependent child first becomes covered under the group health plan, he and/or she must be provided an Initial Notification of COBRA Rights. A sample Initial Notice of COBRA Rights is included in your COBRA Compliance Implementation Kit. New Qualifying Events Any of the following events that would cause an employee, spouse or dependent to lose coverage under the group health plan is considered a COBRA Qualifying Event: Termination of the employee s employment for any reason other than gross misconduct (layoff, resignation, retirement, etc.) Employee s reduction of hours Death of the covered employee Divorce or legal separation from the covered employee Dependent child of the covered employee ceasing to meet eligibility requirements under the Group Health Plan Covered employee/retiree becomes entitled to Medicare Retiree or retiree s spouse or child loses coverage within one (1) year before or after the commencement of proceedings of the sponsoring employer under Title II (bankruptcy), United States Code. An individual who loses coverage under the group health plan because of a Qualifying Event is a Qualified Beneficiary. 1. When a Qualifying Event causes an employee or a dependent to lose coverage under the group health plan, you must mail a COBRA Notification Form to the Qualified Beneficiary within fourteen (14) days of the Qualifying Event; even if the Qualified Beneficiary tells you he or she does not want continuation coverage. The Department of Labor has indicated the best method of delivery to the Qualified Beneficiary is by properly addressed First-Class Mail. 2. Remove the top page of the COBRA Notification and Election Booklet. Complete the COBRA Notification Form as indicated on the first page of the booklet, "Employer Instructions" and on the "Sample Form" page of the booklet. 3. Remove the blue-bordered and pink-bordered copies of the COBRA Notification Form from the booklet. Within fourteen (14) days of the Qualifying Event, mail all remaining pages via First- Class Mail, together with a copy of the COBRA Rate Sheet, to the Qualified Beneficiary and spouse by name, and eligible dependents, if covered under the group health plan to their last- known home address (i.e., John Smith and Mary Smith and Eligible Dependents). 4. Mail the blue bordered COBRA Notification Form to CobraServ within 14 days of the Qualifying Event. Please, DO NOT FAX the form to us. 5. Retain the pink-bordered "Employer Copy" of the form for your records. 6. Terminate this person from your group insurance plan, effective as of the "Benefits Termination Date." If you have any questions regarding the Initial Notice or if you need assistance in completing the COBRA Notification Form, please call CobraServ Client Services at 800/488-8757. We also have a separate toll-free dedicated COBRA continuant line, 800/877-7994.

Managed business solutions for human resources and employee effectiveness Reports / Carrier Updating CobraServ will send you reports of: COBRA continuants electing COBRA and paying the first premium; dependents being added or dropped; continuants being cancelled. WHAT TO DO WITH REPORTS Participant Update, Monthly Participant Status, Premium Distribution Reports Your role is to review these reports, and report the addition, termination or dependent change to the appropriate carrier(s). Description of the Reports Participant Update Reports are generated by CobraServ and sent to the employer providing detail of continuants who make the initial COBRA premium payment, cancellations, or change of their dependents status. These reports are sent on a daily or weekly basis and provide you with the information needed to update your carrier. Once a month, the employer receives the Monthly Participant Status Report from CobraServ and a Premium Distribution Report summarizing all activity for the previous month and a consolidated check for the premiums collected, less the 2% administrative fee paid by the continuant. The next three pages will provide you some sample reports.

Managed business solutions for human resources and employee effectiveness PARTICIPANT UPDATE REPORT SAMPLE REPORT (Provided immediately upon election with payment, cancellation, reinstatement or addition/deletion of dependents)

Managed business solutions for human resources and employee effectiveness PARTICIPANT STATUS SAMPLE REPORT (Provided monthly)

Managed business solutions for human resources and employee effectiveness PREMIUM DISTRIBUTION SAMPLE REPORT (Provided monthly) SAMPLE MONTHLY PREMIUM REIMBURSEMENT

Managed business solutions for human resources and employee effectiveness COBRA COMPLIANCE REQUIREMENTS Who has to Comply? Every employer (except "church groups") who maintains a group health insurance plan, and who employs 20 or more full- and/or part-time employees during 50% of the business days in the preceding calendar year or as further defined under the 2001 Final COBRA Regulations. Notification of Rights 1. The employer or the plan administrator must notify every employee and every covered spouse of all of their rights under COBRA within 90 days of becoming covered under the group health plan. Separate notices must be sent if separate residences are maintained. This applies to all current and future employees and covered spouses. 2. Each time a Qualifying Event occurs, the employer must, within 14 days of notification to the Plan Administrator, notify each Qualified Beneficiary of his/her continuation rights, benefits and premium rates for the plan(s) in which they're eligible. For either kind of notification, good faith compliance has been defined as First-Class Mail, addressed to both the employee and spouse and sent to the last known home address. If covered dependents live at a separate address, separate notifications must be sent. Election Rights When a Qualifying Event causes loss of coverage, the employer must allow continued coverage under the group health plan for up to 18 months in the case of termination of employment or reduction in hours, or up to 36 months for a dependent Qualifying Event. A second Qualifying Event for a dependent occurring during the 18-month coverage period of the first Qualifying Event expands the original period to 36 months. What is a Qualifying Event? Any of the following events causing a loss of coverage by a Qualified Beneficiary under the plan: 1. Termination (other than for gross misconduct) of the employee's employment, for any reason (layoff, resignation, retirement, etc.); 2. Reduction of hours worked by employee; 3. Death of the employee; 4. Divorce or legal separation; 5. Dependent child ceasing to meet eligibility requirements; 6. Dependent coverage is lost because the active employee (or COBRA continuant) becomes entitled to Medicare. 7. Retiree or retiree's spouse or child loses coverage within one year before or after the commencement of proceedings under Title 11 (bankruptcy), United States Code of the sponsoring employer. Who is a Qualified Beneficiary? Any employee, spouse or dependent child who was covered on the day before the Qualifying Event and who would otherwise lose coverage under the plan because of the Qualifying Event. This definition also includes a child born to or placed for adoption with a covered employee during the period of COBRA coverage. Election Timeframe Qualified Beneficiaries are allowed to buy continuation coverage retroactive to the benefit termination date. They are entitled to make this election within 60 days of the date of the notification of their rights or the date that benefits would terminate, whichever is later. If they decline, they may change their minds and elect if they are still within the 60-day election period. Choices of Coverage Each Qualified Beneficiary must be allowed to make an independent election. For example, if the plan contains medical and dental coverage, the employee may decline coverage, the spouse may elect medical only, and the child may elect medical and dental. Dependents You must allow 'branching" of coverage. If a continuant elects family coverage, his or her dependent(s) are allowed to continue benefits if/when they would otherwise cease to be eligible under the contract as dependents during the 18-36-month continuation period. Qualified Beneficiaries other than the covered employee may continue coverage for up to 36 months from the date of the covered employee's Medicare entitlement, if the covered employee becomes entitled to Medicare and, within 18 months thereafter, has a Qualifying Event. You must allow continuants to add dependents if the dependents meet the special enrollment rules under the Health Insurance Portability and Accountability Act (HIPAA) or if the continuants acquire any new dependents after their Qualifying Event if such a right applies to similarly situated active employees. Ongoing Administration You must allow continuants to change benefits annually if the option is available to active employees (i.e., flexible benefits plans/hmo dual option plans). Open Enrollment periods must be allowed for continuants on the same basis as for active employees. Continuants must be offered a conversion privilege at the end of the 18- or 36-month period, if one is available to active employees. You must allow existing COBRA continuants to continue coverage as long as they meet the eligibility requirements, even if your group size fails below 20 full-time andlor part-time employees. Payments The employer or plan administrator must allow continuants to pay their first premium within 45 days of the date they elect coverage, if coverage is elected within the 60-day election period. You may not require any premium payment until 45 days from the date of election. You must allow a grace period of not less than 30 days for the payment of all subsequent premiums. Disability Extension A Qualified Beneficiary's (and that of any other covered members of the family) continuation period must be extended to 29 months from 18 months if the Social Security Administration determines that the Qualified Beneficiary was totally disabled under Title 11 or XVI of the Social Security Act on the day of the Qualifying Event, or within the first 60 days of COBRA coverage, and the Qualified Beneficiary sends a copy of the determination notice to Cobra- Serv before the end of the initial 18-month period and within 60 days of the date of the notice from the SSA. Other Coverages You must allow continuant(s) to continue COBRA coverage despite their becoming covered under a new group health plan if the new plan contains an exclusion or limitation with respect to any pre-existing condition of that continuant. See Your Attorney The complexity of the law and the fact that judicial decisions affecting compliance can happen at any time precludes a complete description of legal requirements. Please consult your attorney.

Learn more online at www.ceridian.com/myceridian MANAGED BUSINESS SOLUTIONS Best in class solutions. Extraordinary expertise. Proven service for thousands of companies around the world. Ceridian frees your company to maximize your human, financial and technological resources and get them focused on what s really important your business. Ceridian 3201 34th Street South St. Petersburg, FL 33711 www.ceridian.com/myceridian 2003 Ceridian Corporation. All rights reserved. Printed in USA MP-030625 CAP

*VERY IMPORTANT NOTICE* INITIAL NOTICE OF COBRA RIGHTS EMPLOYER FROM: Contact Person/Department: NAME PHONE DATE: TO: NAME ADDRESS CITY/ST/ZIP (employer completes both address sections) A federal law known as COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985 as amended) requires most employers sponsoring group health plans to notify all of their employees, including newlyhired, current and previous employees (and their dependents) of their rights to continuation health care coverage in the event they would lose coverage due to certain events called Qualifying Events. This notice is the employer s fulfillment of this obligation. If you, your spouse or dependent child(ren) are or become participants in the above employer s group health plan(s), it is important to understand your ongoing rights and obligations under the continuation of coverage provisions of COBRA. This summary of rights should be reviewed by both you and your spouse (if applicable), retained with other benefits documents, and referred to in the event that any action is required on your part. If you, your spouse or dependent child(ren) should lose coverage under the above employer s group health plan(s) due to a Qualifying Event (listed below), you may be entitled to elect temporary continuation of health care coverage ( continuation coverage ) at group rates. It is important that your sponsoring employer have your current address. Notification of a Qualifying Event should one occur, will be sent to your last known address at the time of the event. The following summary of information concerning COBRA outlines the procedures which should be followed if or when a Qualifying Event occurs. If you are an employee of the employer designated in the EM- PLOYER box above and are covered by its group health plan, you have a right to elect continuation coverage if you lose your group health coverage because of a reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct). If you are the covered spouse of the above covered employee, you have the right to elect continuation coverage for yourself if you lose group health coverage for any of the following reasons: (1) The death of your spouse; (2) The termination of your spouse s employment (for reasons other than gross misconduct) or reduction in your spouse s hours of employment; (3) Divorce or legal separation from your spouse; or (4) Your spouse becomes entitled to Medicare. If you are a covered dependent child of the above employee, you have the right to elect continuation coverage if you lose group health coverage for any of the following reasons: (1) The death of the employee; (2) The termination of the employee s employment (for reasons RETAIN THIS NOTICE WITH YOUR INSURANCE PAPERS other than gross misconduct) or a reduction in the employee s hours of employment; (3) Parents' divorce or legal separation; (4) Employee becomes entitled to Medicare; or (5) The dependent ceases to be a dependent child under the terms of the plan(s). You also have a right to elect continuation coverage if you are covered under the plan as a retiree or spouse or child of a retiree, and lose coverage within one year before or after the commencement of proceedings under Title 11 (bankruptcy), United States Code. Under the law, the employee (or a covered dependent) has the responsibility to inform the above named employer of a divorce, legal separation, or a child losing dependent status under the plan if any of these events would cause a loss of coverage. This notification must be made within 60 days after the date of the Qualifying Event, or the date on which coverage would end under the plan because of the event, whichever is later. The notice must be in writing, and should be sent to the contact person or department of the employer indicated on this form. If notice is not timely made, rights to continue coverage will terminate. In situations where a covered employee discontinues coverage of a spouse in anticipation of a divorce or legal separation, your sponsoring employer, who received timely notification, is required to make COBRA continuation coverage available effective from the date of the divorce or legal separation (but not prior to that date). If you need help acting on behalf of an incompetent beneficiary, please contact the employer indicated for assistance. When the employer is notified that a Qualifying Event has happened, it will in turn notify you that you have the right to elect continuation coverage. Under the law, you have 60 days from the date you would lose coverage because of one of the events described above, or 60 days from the date of the employer s notice of your right to elect continuation coverage (whichever is later) to elect continuation coverage. If you make a timely election, coverage will become effective on the day after coverage would otherwise be terminated. Note: Some states offer financial aid to help certain individuals pay for COBRA coverage. Contact your appropriate state agency regarding availability and eligibility requirements. Additionally, under certain circumstances, COBRA coverage may be paid with pre-tax dollars from a cafeteria plan under Section 125. If you do not timely elect continuation coverage, your group health insurance coverage will terminate in accordance with the provisions outlined in your employer s plan. If you elect continuation coverage, your coverage will be identical to the coverage provided under the plan to similarly situated employees and their family members. The law requires that you be afforded the opportunity to maintain continuation coverage for 36 months from the date of the Qualifying Event, unless coverage was lost because of a termination of employment or a reduction in hours. In that case, the required continuation coverage period is 18 months measured from the Qualifying Event date. The 18-month period may be extended to 29 months for disabled Qualified Beneficiaries under certain circumstances, as described on the reverse side of this notice. However, the law also provides that continuation coverage may end prior to the expiration of the 18-, 29- or 36-month period described above if any one of the following occurs: The Qualified Beneficiary fails to pay the required premium in a timely manner; The Qualified Beneficiary first becomes, after the date of election, Continued on next page CS-306/2/02SAL ORIGINAL EMPLOYEE COPY EMPLOYER 2002 Ceridian Corporation

INITIAL NOTICE OF COBRA RIGHTS (continued) entitled to Medicare; The employer/former employer no longer provides group health coverage to any of its employees; The Qualified Beneficiary first becomes, after the date of election, covered under another group health plan (as an employee or otherwise) which does not contain any exclusion or limitation with respect to any preexisting condition of the Qualified Beneficiary. You do not have to show that you are insurable to choose continuation coverage. However, continuation coverage under COBRA is provided subject to your eligibility for coverage under the plan. The employer reserves the right to terminate your continuation coverage retroactively if you are determined to be ineligible. Under the law, you may have to pay all or part of the premium for your continuation coverage. Your employer may charge you up to 102% of the applicable premium for your continuation coverage. The law also says that, at the end of the 18-month, 29-month or 36-month continuation coverage period, you must be allowed to enroll in an individual conversion health plan if one is provided under the terms of the employer s group health plan. In addition, under the Health Insurance Portability & Accountability Act (HIPAA, 1996), in certain circumstances, such as when you exhaust COBRA coverage, you may have the right to buy individual health coverage with no pre-existing condition exclusion without having to give evidence of good health. Once your continuation coverage terminates for any reason, it cannot be reinstated. Please notify the contact person or department indicated in the EMPLOYER box on the front side of this notice if: you have any questions about this material; you have a change in marital status, or you, your spouse, or eligible covered dependent has a change of address. Also, if your spouse or any covered child resides at a different address, please notify the employer in writing, so that a separate notice may be sent. COBRA Questions and Answers A) Who is a Qualified Beneficiary? A Qualified Beneficiary is any employee, former employee, or spouse or dependent child of an employee or former employee, who was covered under the employer s group health plan on the day before the Qualifying Event. The definition also includes a child born to or placed for adoption with a covered employee during the period of COBRA coverage. B) What is a Qualifying Event? A Qualifying Event is any of the following events which would cause an employee, former employee, covered spouse or covered dependent child to lose coverage under the employer s group health plan. These events include: a) with respect to a Qualified Beneficiary, an employee s termination of employment (includes voluntary resignation and involuntary termination, except when termination is due to gross misconduct), retirement, or layoff; b) with respect to a Qualified Beneficiary, an employee s reduction of work hours (includes work stoppage, strike, or employee begins leave of absence); c) with respect to a Qualified Beneficiary other than the employee, death of a covered employee; d) with respect to a Qualified Beneficiary other than the employee, divorce or legal separation from a covered employee; e) with respect to a Qualified Beneficiary other than the employee, a dependent child s loss of eligibility due to the plan s eligibility definitions; f) with respect to a Qualified Beneficiary other than the employee, an employee becoming entitled to Medicare. g) with respect to a retiree or spouse or child of a retiree, loss of coverage within one year before or after the sponsoring employer s commencement of proceedings under Title 11 (bankruptcy), United States Code. C) How long may coverage be continued? If the Qualifying Event is either (a) or (b) in question B above, coverage may be continued for up to 18 months,* which is measured from the date of the Qualifying Event. For Qualified Beneficiaries other than the covered employee, coverage may be continued for: (i) up to 36 months from any other Qualifying Event, which is measured from the date of the original Qualifying Event, or, (ii) up to 36 months measured from the date of the covered employee's Medicare entitlement, if the covered employee becomes entitled to Medicare and, within 18 months thereafter, has a Qualifying Event (either "(a)" or "(b)" in question B above). However, continuation coverage may end prior to the expiration of the 18-, 29- or 36-month period, as described on the reverse side of this notice. *Note: A Qualified Beneficiary who is determined under Title II or XVI of the Social Security Act, to have been disabled at the time of a Qualifying Event or within the first 60 days of COBRA coverage described in (a) or (b) in question B above may be eligible to continue coverage for an additional 11 months (29 months total). In order to obtain this extension of coverage, the Qualified Beneficiary must provide the employer with the written determination of disability from the Social Security Administration within 60 days of the date of the determination of disability by the Social Security Administration and prior to the end of the 18-month continuation period. The employer can charge up to 150% of the applicable premium during the 11-month disability extension. If coverage is extended to 29 months, coverage will cease upon a final determination that the Qualified Beneficiary is no longer disabled. The disabled individual must notify the Employer within 30 days of any final determination that he or she is no longer disabled. D) What coverage(s) may be continued? Qualified Beneficiaries may continue only those group health coverages that were in effect on the day before the Qualifying Event. E) Can Qualified Beneficiaries make separate coverage elections? Yes, Qualified Beneficiaries may make separate elections. Each Qualified Beneficiary may choose any benefit coverage for which he or she is eligible. If Qualified Beneficiaries wish to make independent elections, they must complete separate election forms. Parents or guardians may elect coverage on behalf of minor dependent children. F) How much will it cost me to continue coverage under COBRA? The cost to continue coverage is the applicable group premium rate for coverage elected, plus an administration fee, if applicable. Premium rates (including administration fees where applicable) should be provided to you at the time of a Qualifying Event. These rates are subject to change. G) When does COBRA coverage begin? COBRA continuation coverage begins on the day after the date that coverage would otherwise terminate under the plan, only if the election form is sent within the allotted time period and all other eligibility requirements are satisfied. CS-306/2/02SAL ORIGINAL EMPLOYEE COPY EMPLOYER 2002 Ceridian Corporation

COBRA Continuant Takeover Form PLEASE CHECK ONE BOX 1a) FROM: (COMPANY) ORIGINAL NOTICE If FAXED, do not mail copy. REVISION... to a form that was previously sent. INSTRUCTIONS: Please type or print, IN BLACK OR BLUE INK, clearly. Fill out just one form per family unit (Qualified Beneficiary and dependents). Use this form to report existing COBRA continuants who will be transferred to CobraServ. Please do not use this form to report new Qualifying Events. Use the Qualifying Event Notification Form. COMPLETE THIS FORM AND RETURN IT TO: CobraServ National Service Center, P.O. Box 534066, St. Petersburg, FL 33747-4066 Telephone: 800/488-8757 Fax: 727/865-3648 CS-614/6/00CAP (For transferring current COBRA continuants to CobraServ) 1b) Plan Code (Division Code) Company Code (Unit Code) (If applicable, refer to the Client Rate Report for the one character or two characters required [alpha and/or numeric] to complete above.) 2) CobraServ Account # (indicated on the Client Rate report for location or subsidiary) 14) First premium due-date for which CobraServ is to begin billing. M M D D Y Y Y Y 15) COBRA Qualifying Event that caused loss of coverage (check one) Continuation of coverage for 18 months: (Code 1) Employee s termination of employment (includes voluntary resignation, involuntary termination (except when due to gross misconduct), retirement, layoff, or leave of absence) (Code 2) Employee s reduction in work hours (includes work stoppage or strike) Continuation of coverage for 36 months: Death of covered employee /retiree (Code 3) (Code 6) Ineligibility of dependent child (Code 4) Divorce/legal separation Retiree, spouse or child of retiree loses Covered employee/retiree becomes entitled to Medicare; dependents may elect continuance of identical coverage (Code 5) (Code 7) States Code coverage within one year before or after commencement of proceedings under Title 11 (bankruptcy) United 16) If employee, does he/she have a health care Flexible Spending Account (FSA)? (N)o (Y)es If Yes, MONTHLY contribution $ 17) Benefits Class (Refer to Client Rate Report for Code) 3) Please be advised that the following is currently on COBRA continuation. (Check one box only.) (E)mployee (D)ependent 4) Social Security Number of Qualified Beneficiary 5a) Name of COBRA continuant (last, first, mi) 5b) Street (include apartment number) 5c) City 5d) State 5e) Zip Code 6) Home Phone # (if available) 7) Employee Number (if applicable) 8) Date of Birth 9) Gender (check one) (M)ale (F)emale M M D D Y Y Y Y 10) Marital Status (Check one box only.) (S)ingle (M)arried (W)idowed (D)ivorced 11) If the above individual in box #5 is a dependent of an employee/former employee, please complete the following: Employee Name (last, first, mi) Employee SSN Dependent s Relationship to Employee 12) Qualifying Event Date M M D D Y Y Y Y 13) Last day of pre-cobra Coverage (cannot be prior to Qualifying Event Date) M M D D Y Y Y Y 18) Check the current plan code coverages. CobraServ administers only plan code coverage options that are permitted by your plan or carrier. (Check one box only.) 1 = Individual 9 = Individual + Spouse 2 = Individual + 1 14 = Individual + Child 3 = Family 15 = Individual + Children 19) Has the continuant been approved for an additional 11-month disability extension? (N)o (Y)es 20) If the COBRA continuant has dependents covered, please complete the following. If names are not available, please indicate N/A. Dependent Name (first, last, mi) Date of Birth (month/day/year) Gender(check one) (M)ale (F)emale Social Security Number Relationship to employee Qualified Beneficiary Dependent Name (first, last, mi) Date of Birth (month/day/year) Gender check one) (M)ale (F)emale Social Security Number Relationship to employee Qualified Beneficiary Dependent Name (first, last, mi) Date of Birth (month/day/year) Gender (check one) (M)ale (F)emale Social Security Number Relationship to employee Qualified Beneficiary Prepared By: Name: (Print) Date: Phone #: Fax #: M M D D Y Y Y Y CobraServ National Service Center 3201 34th Street South St. Petersburg, Florida 33711-3828 800/488-8757 Fax: 727/865-3648 2000 Ceridian Corporation

TRANSFERRING CURRENT COBRA CONTINUANTS TO COBRASERV INSTRUCTIONS FOR COMPLETING COBRASERV CONTINUANT TAKEOVER FORM (ON REVERSE SIDE) (USE ONE FORM PER FAMILY UNIT) This form is only needed if you have current COBRA Continuants to be transferred to CobraServ. One form should be completed for each family unit and sent to: CobraServ National Service Center, P.O. Box 534066, St. Petersburg, FL 33747-4066 Number 1: Number 2: Number 3: Number 4: Number 5: Enter your company name. If we have set up your account to report by division or unit, enter division or region code and company ID or unit code. Enter your company s CobraServ Account Number. Check appropriate box to indicate whether Continuant is an employee or dependent. (Check one box only.) Enter the Continuant s complete ninedigit Social Security Number. Enter Continuant s complete name (last, first, middle initial) and complete mailing address (street, city, state and Zip Code). Number 13: Number 14: Number 15: Number 16: Enter the LAST DAY (month, day, year) of the Continuant s pre-cobra coverage. Enter the FIRST PREMIUM DUE DATE for which CobraServ is to begin billing. Check appropriate box (check one box only) to indicate the type of Qualifying Event. Employee s termination of employment includes voluntary resignation, involuntary termination (except for termination due to gross misconduct), retirement, layoff, or leave of absence. Employee s reduction in hours includes work stoppage (strike). If the employee has a health care Flexible Spending Account (FSA), check Yes and indicate his or her monthly contribution. Number 6: Number 7: Number 8: Number 9: Number 10: Number 11: Number 12: Enter Continuant s home phone number, including area code, if available. If the Continuant is an employee who has an employee ID number, enter it here. Continuant s date of birth. (month, day, year). Check appropriate box to indicate the Continuant s Gender (Male or Female). Check appropriate box to indicate marital status of Continuant. If the Continuant is a dependent of an employee or former employee, enter employee s complete name (last, first, middle initial), employee s ninedigit Social Security Number, and Continuant s relationship to employee. Enter the month, day and year of the Qualifying Event. Number 17: Number 18: Number 19: Number 20: Refer to your COBRA Rate Sheet and enter the CobraServ Benefits Class indicating the coverage in effect for this individual. Indicate coverage by checking the box of the appropriate plan code. Your carrier may not use some of the choices indicated: check the choice that corresponds to the status assigned this individual by your carrier. Check appropriate box (Yes or No) to indicate whether the Continuant has been approved for an 11-month disability extension. Provide information if the Continuant has dependents covered, and indicate whether the individual is a Qualified Beneficiary and was covered under the group health plan at the time of the original Qualifying Event or was born to or placed for adoption with a covered employee during the period of COBRA coverage. PLEASE BE SURE TO COMPLETE ALL ITEMS AND TO SIGN AND DATE FORM. INCOMPLETE FORMS WILL BE RETURNED FOR COMPLETION. CS-614/6/00CAP CobraServ National Service Center 3201 34th Street South St. Petersburg, Florida 33711-3828 800/488-8757 Fax: 727/865-3648 2000 Ceridian Corporation

COBRA PROCEDURES MANUAL Outlining the policies and procedures followed by our organization in the fulfillment of COBRA requirements. This document is supplied solely for the purpose of assisting you in organizing documentation of your internal COBRA administration practices. To the extent that any of the information contained in this document is inconsistent with IRS requirements, IRS requirements will govern in all cases. We suggest that you have this document reviewed by your accountant and/or attorney. OUR COBRA ADMINISTRATION PROCEDURES: OUR COBRA ADMINISTRATION SYSTEM: COBRA administration functions are performed jointly by our organization and CobraServ, a national COBRA compliance administrator. (Within our organization, COBRA functions are handled by: Our CobraServ contact is: Client Services Department CobraServ National Service Center 3201 34th Street South St. Petersburg, Florida 33711-3828 Phone: 800/488-8757 CobraServ will provide all documentation related to the administrative functions it has performed on our behalf if requested in connection with an IRS audit. OUR PROCEDURES Initial Notification of COBRA Rights (check box(es) that apply): (Internal person responsible: ) Each time an employee and/or spouse becomes covered under our plan, they are notified of their COBRA rights as follows: CobraServ sends an Initial Notice of COBRA Rights Form, based upon the Department of Labor Model Notice, via First Class Mail with proof of mailing addressed to the employee and spouse at the last known home address. If spouse resides at a different address, notices are sent to both addresses. Proof of mailing is archived for 7 years. We send a copy of CobraServ-provided Initial Notice of COBRA Rights Form #CS-306 via First Class Mail addressed to the employee and spouse at the last known home address. If spouse resides at a different address, notices are sent to both addresses. We retain a copy of this form, which includes addressee information and date sent, on file for 7 years for our records. We send a reproduction of the Initial Notice of COBRA Rights Form, based upon the Department of Labor Model Notice, via First Class Mail addressed to the employee and spouse at the last known home address. If spouse resides at a different address, notices are sent to both addresses. We retain copies of these notices for years, and store them (location).

All of our currently-covered employees and spouses have been properly provided with an Initial Notice of COBRA Rights. We retain copies of these notices for years, and store them (location). OUR PROCEDURES COBRA Qualifying Event Notifications: (Internal person responsible: ) Each time an employee or dependent has a Qualifying Event, we perform the following procedures: 1. Remove the top page entitled Employer Instructions. 2. Fill out COBRA Notification page of the of multi-part COBRA Notification/Election booklet #CS-205C. 3. Address it to both employee and spouse, if spouse is covered, at their last known home address (form is designed for a standard window envelope). 4. Enclose a copy of the COBRA Rate Sheet applicable to the recipient. 5. Retain the pink banded copy of the form for our files, and send the blue banded copy to CobraServ (which they retain in archive for seven years). 6. Mail the Notification/Election booklet via First Class Mail within 14 days of the Qualifying Event and retain proof of mailing. 7. Terminate the person from our group insurance plan. CobraServ handles all subsequent administration related to the Qualifying Event. OUR PROCEDURES Billing/Collecting/Ongoing Eligibility Adjudication: (Internal person responsible: ) 1. CobraServ handles receipt, adjudication and processing of COBRA elections, and also handles all of our COBRA premium billing and collecting. 2. CobraServ sends us a Participant Status Update report each time a COBRA continuant elects and pays the first premium, a dependent is added or dropped, or a continuant is cancelled. 3. We use this report to update our carrier on COBRA continuants. 4. Once a month, CobraServ sends us a complete summary of our COBRA activity for the previous month, together with a check for the premiums collected. 5. We check this report against our own records to verify that all proper COBRA administrative activities have taken place. We also forward premium payments directly to the applicable insurance carrier. OUR PROCEDURES Maintaining copies of standard form letters sent to Qualified Beneficiaries regarding continuation coverage. (Forms specified by the IRS as required for audit purposes should be attached to this document. NOTE: Forms used by CobraServ for such communications during the period in which CobraServ services were in effect will be provided by CobraServ when requested at the time of audit.)

(Internal person responsible: ) FORMS ATTACHED (check applicable items): Forms used prior to utilization of CobraServ administration services. Non-CobraServ forms currently in use. Current version of CobraServ forms have been requested (at time of audit only). OUR INTERNAL AUDIT PROCEDURES RELATED TO COBRA: Following are the audit procedures we use to ensure that all aspects of COBRA compliance are being properly administered. (Auditing of CobraServ-performed functions is accomplished by reconciling our internal COBRA records with reports provided by CobraServ as COBRA-related activities occur, and monthly summary reports.) Listed below are the COBRA administration functions, the person responsible for auditing them, the audit method, and the audit timeframe. Function Audited by Audit Method & Frequency Sending of Initial Notices to newly-covered employees and spouses Qualifying Event Discovery Sending of Qualifying Event Notices with Rate Sheets Reconciling internal records of COBRA activities with reports provided by CobraServ Adding or deleting persons to/from the group health plan in response to COBRA status communicated by CobraServ

COPIES OF ALL GROUP HEALTH PLANS: Accompanying this document are copies of all group health plans in force for our organization. (Check this box as complete after you have attached copies of all of your group health plans, to include policy, Summary Plan Description, and all amendments and riders.) DETAILS PERTAINING TO ANY PAST REQUEST FOR CONTINUED COVERAGE AND/OR PENDING LAWSUITS RELATING TO COBRA COVERAGE: Accompanying this document are records of past requests for continued coverage and details of pending lawsuits (including pleadings, complaints, answers, etc.) relating to COBRA coverage. (NOTE: CobraServ keeps copies of all request letters and correspondence related to requests for continued coverage, and will make them available upon request at the time of audit.) (Check this box as complete after you have attached copies of all items requested.) MAINTENANCE OF RECORDS: Accompanying this document is information concerning all employees who have left our employment during the current and 6 preceding tax years. If we cover any independent contractors under our group health plans, a similar list for them is provided.* (Check this box as complete after you have attached the lists requested.) Information to include: a) Name b) Address c) Marital Status d) Health plan selected, and whether such plan covered the family or just the employee. e) Dental plan selected, and whether such plan covered the family or just the employee. f) Date of termination from the company. g) Date that COBRA Continuation Coverage was made available to the terminated employee. h) Date that COBRA Continuation Coverage was made available to the spouse and/or dependents of the terminated employee. i) With regard to items (g) and (h), was this notice written or oral? j) With regard to items (g) and (h), was a separate notice given to each party? k) With regard to items (g) and (h), was the notice hand delivered or mailed? l) Was COBRA Continuation Coverage accepted or rejected by the employee and/or spouse. m) Was the termination of the employee voluntary or involuntary? *NOTE: The Pink banded copies of form CS-205C provide the majority of information required. CS-802/8/02 CAP 2002 Ceridian