Initial Notice of COBRA Rights COBRA INITIAL/GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS Introduction **CONTINUATION COVERAGE RIGHTS UNDER COBRA** C&A Industries, Inc. C&A Industires, Inc. Benefits Plan (the Plan), has three group health components, Medical, Dental, and Health FSA. You may be enrolled in one or more of these components. This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of group health coverage under the Plan under certain circumstances when coverage would otherwise end. This notice generally explains COBRA coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. COBRA (and the description of COBRA coverage contained in this notice) applies only to the group health plan benefits offered under the Plan (the Medical, Dental, and Health FSA components) and not to any other benefits offered under the Plan or by C&A Industries, Inc. (such as life insurance, disability, or accidental death or dismemberment benefits). The right to COBRA coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA coverage can become available to you when you would otherwise lose your group health coverage under the Plan. It can also become available to your spouse and dependent children, if they are covered under the Plan, when they would otherwise lose their group health coverage under the Plan. This notice does not fully describe COBRA coverage or other rights under the Plan. 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 C&A Industries, Inc., which is the Plan administrator. The Plan provides no greater COBRA rights than what COBRA requires nothing in this notice is intended to expand your rights beyond COBRA s requirements. What is COBRA Coverage? COBRA 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 occurs and any required notice of that event is properly provided to C&A Industries, Inc., COBRA coverage must be offered to each person losing Plan coverage who is a qualified beneficiary. You, your spouse, and your dependent children could become qualified beneficiaries and would be entitled to elect COBRA if coverage under the Plan is lost because of the qualifying event. (Certain newborns, newly adopted children, and alternate recipients under QMCSOs may also be qualified beneficiaries. This is discussed in more detail in separate paragraphs below.) Under the Plan, qualified beneficiaries who elect COBRA must pay for COBRA coverage.
Initial Notice of COBRA Rights Who is entitled to elect COBRA? If you are an employee, you will be entitled to elect COBRA if you lose your group health coverage under the Plan because either one of the following qualifying events happens: your hours of employment are reduced; or your employment ends for any reason other than your gross misconduct. If you are the spouse of an employee, you will be entitled to elect COBRA if you lose your group health coverage under the Plan because any of the following qualifying events happens: your spouse dies; your spouse s hours of employment are reduced; your spouse s employment ends for any reason other than his or her gross misconduct; or you become divorced or legally separated from your spouse. Also, if your spouse (the employee) reduces or eliminates your group health coverage in anticipation of divorce or legal separation, and a divorce or legal separation later occurs, then the divorce or legal separation may be considered a qualifying event for you even though your coverage was reduced or eliminated before the divorce or separation. A person enrolled as the employee s dependent children will be entitled to elect COBRA if he or she loses group health coverage under the Plan because any of the following qualifying events happens: the parent-employee dies; the parent employee s hours of employment are reduced; the parent-employee s employment ends for any reason other than his or her gross misconduct; the child stops being eligible for coverage under the Plan as a dependent child. When is COBRA Coverage Available? When the qualifying event is the end of employment or reduction of hours of employment or death of the employee, the Plan will offer COBRA to qualified beneficiaries. You need not notify C&A Industries, Inc. of any of these three qualifying events. You Must Give Notice of Some Qualifying Events For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child s losing eligibility for coverage as a dependent child), a COBRA election will be available to you only if you notify C&A Industries, Inc. in writing within 60 days after the later of (1) the date of the qualifying event; and (2) the date on which the qualified beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the qualifying event. In providing this notice, you must use the attached form entitled Notice of Qualifying Event (Form & Notice Procedures), and you must follow the Notice Procedures for Notice of Qualifying Event that appear at the end of the form. If these procedures are not followed or if the notice is not provided in writing to C&A Industries, Inc. during the 60-day notice period, YOU WILL LOSE YOUR RIGHT TO ELECT COBRA. (The Notice of Qualifying Event (Form & Notice Procedures) is attached to and is a part of this initial notice; a copy of the Notice of Qualifying Event (Form & Notice Procedures) can also be obtained from C&A Industries, Inc.)
Initial Notice of COBRA Rights Electing COBRA Each qualified beneficiary will have an independent right to elect COBRA. Covered employees and spouses (if the spouse is a qualified beneficiary) may elect COBRA on behalf of all of the qualified beneficiaries, and parents may elect COBRA on behalf of their children. Any qualified beneficiary for whom COBRA is not elected within the 60-day election period specified in the Plan s COBRA election notice WILL LOSE HIS OR HER RIGHT TO ELECT COBRA COVERAGE. Qualified beneficiaries may be enrolled in one or more group health components of the Plan at the time of a qualifying event (the components are Medical, Dental, and Health FSA). If a qualified beneficiary is entitled to a COBRA election as the result of a qualifying event, he or she may elect COBRA under any or all of the group health components of the Plan under which he or she was covered on the day before the qualifying event. (For example, if a qualified beneficiary was covered under the Medical and Dental components on the day before the qualifying event, he or she may elect COBRA under the Dental component only, the Medical component only, or under both Medical and Dental. Such a qualified beneficiary could not elect COBRA under the Health FSA component, because he or she was not covered under this component on the day before the qualifying event.) Qualified beneficiaries who are entitled to elect COBRA may do so even if they have other group health plan coverage or are entitled to Medicare benefits on or before the date on which COBRA is elected. However, a qualified beneficiary s COBRA coverage will terminate automatically if, after electing COBRA, he or she becomes entitled to Medicare benefits or becomes covered under other group health plan coverage (but only after any applicable preexisting condition exclusions of that other plan have been exhausted or satisfied). How Long Does COBRA Coverage Last? COBRA coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the covered employee s divorce or legal separation, or a dependent child s losing eligibility as a dependent child, COBRA coverage can last for up to a total of 36 months. However, COBRA coverage under the Health FSA component can last only until the end of the year in which the qualifying event occurred see the paragraph below entitled Health FSA Component. When the qualifying event is the end of employment or reduction of the employee s hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA coverage for qualified beneficiaries (other than the employee) who lose coverage as a result of the qualifying event can last until up to 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare eight months before the date on which his employment terminates, COBRA coverage under the Plan s Medical and Dental components for his spouse and children who lost coverage as a result of his termination can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus eight months). This COBRA coverage period is available only if the covered employee becomes entitled to Medicare within 18 months BEFORE the termination or reduction of hours. However, COBRA coverage under the Health FSA component can last only until the end of the year in which the qualifying event occurred see the paragraph below entitled Health FSA Component.
Initial Notice of COBRA Rights Otherwise, when the qualifying event is the end of employment or reduction of the employee s hours of employment, COBRA coverage generally can last for only up to a total of 18 months. However, COBRA coverage under the Health FSA component can last only until the end of the year in which the qualifying event occurred see the paragraph below entitled Health FSA Component. The COBRA coverage periods described above are maximum coverage periods. COBRA coverage can end before the end of the maximum coverage periods described in this notice for several reasons, which are described in the Plan s summary plan description. There are two ways in which the period of COBRA coverage resulting from a termination of employment or reduction of hours can be extended. (The period of COBRA coverage under the Health FSA cannot be extended under any circumstances.) Disability extension of COBRA coverage If a qualified beneficiary is determined by the Social Security Administration to be disabled and you notify C&A Industries, Inc. in a timely fashion, all of the qualified beneficiaries in your family may be entitled to receive up to an additional 11 months of COBRA coverage, for a total maximum of 29 months. This extension is available only for qualified beneficiaries who are receiving COBRA coverage because of a qualifying event that was the covered employee s termination of employment or reduction of hours. The disability must have started at some time before the 61 st day after the covered employee s termination of employment or reduction of hours and must last at least until the end of the period of COBRA coverage that would be available without the disability extension (generally 18 months, as described above). The disability extension is available only if you notify C&A Industries, Inc. in writing of the Social Security Administration s determination of disability within 60 days after the latest of: the date of the Social Security Administration s disability determination; the date of the covered employee s termination of employment or reduction of hours; and the date on which the qualified beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the covered employee s termination of employment or reduction of hours. You must also provide this notice within 18 months after the covered employee s termination of employment or reduction of hours in order to be entitled to a disability extension. In providing this notice, you must use the Notice of Disability (Form & Notice Procedures), and you must follow the Notice Procedures for Notice of Disability that appear at the end of the form. If these procedures are not followed or if the notice is not provided in writing to C&A Industries, Inc. during the 60-day notice period and within 18 months after the covered employee s termination of employment or reduction of hours, THEN THERE WILL BE NO DISABILITY EXTENSION OF COBRA COVERAGE. A copy of the Notice of Disability (Form & Notice Procedures) can be obtained from C&A Industries, Inc.
Initial Notice of COBRA Rights Second qualifying event extension of COBRA coverage If your family experiences another qualifying event while receiving COBRA coverage because of the covered employee s termination of employment or reduction of hours (including COBRA coverage during a disability extension period as described above), the spouse and dependent children receiving COBRA coverage can get up to 18 additional months of COBRA 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 COBRA coverage if the employee or former employee dies 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. (This extension is not available under the Plan when a covered employee becomes entitled to Medicare.) This extension due to a second qualifying event is available only if you notify C&A Industries, Inc. in writing of the second qualifying event within 60 days after the later of (1) the date of the second qualifying event; and (2) the date on which the qualified beneficiary would lose coverage under the terms of the Plan as a result of the second qualifying event (if it had occurred while the qualified beneficiary was still covered under the Plan). In providing this notice, you must use the attached form entitled Notice of Second Qualifying Event (Form & Notice Procedures), and you must follow the Notice Procedures for Notice of Second Qualifying Event that appear at the end of the form. If these procedures are not followed or if the notice is not provided in writing to C&A Industries, Inc. during the 60-day notice period, THEN THERE WILL BE NO EXTENSION OF COBRA COVERAGE DUE TO A SECOND QUALIFYING EVENT. A copy of the Notice of Second Qualifying Event (Form & Notice Procedures) can be obtained from C&A Industries, Inc. Health FSA Component COBRA coverage under the Health FSA will be offered only to qualified beneficiaries losing coverage who have underspent accounts. A qualified beneficiary has an underspent account if the annual limit elected by the covered employee, reduced by reimbursements up to the time of the qualifying event, is equal to or more than the amount of the premiums for Health FSA COBRA coverage that will be charged for the remainder of the plan year. COBRA coverage will consist of the Health FSA coverage in force at the time of the qualifying event (i.e., the elected annual limit reduced by expenses reimbursed up to the time of the qualifying event). The use-it-or-lose-it rule will continue to apply, so any unused amounts will be forfeited at the end of the plan year, and COBRA coverage will terminate at the end of the plan year. Unless otherwise elected, all qualified beneficiaries who were covered under the Health FSA will be covered together for Health FSA COBRA coverage. However, each beneficiary has separate election rights, and each could alternatively elect separate COBRA coverage to cover that beneficiary only, with a separate Health FSA annual limit and a separate premium. If you are interested in this alternative, contact C&A Industries, Inc. for more information.
Initial Notice of COBRA Rights More Information About Individuals Who May Be Qualified Beneficiaries Children born to or placed for adoption with the covered employee during COBRA coverage period A child born to, adopted by, or placed for adoption with a covered employee during a period of COBRA coverage is considered to be a qualified beneficiary provided that, if the covered employee is a qualified beneficiary, the covered employee has elected COBRA coverage for himself or herself. The child s COBRA coverage begins when the child is enrolled in the Plan, whether through special enrollment or open enrollment, and it lasts for as long as COBRA coverage lasts for other family members of the employee. To be enrolled in the Plan, the child must satisfy the otherwise applicable Plan eligibility requirements (for example, regarding age). Alternate recipients under QMCSOs A child of the covered employee who is receiving benefits under the Plan pursuant to a qualified medical child support order (QMCSO) received by C&A Industries, Inc. during the covered employee s period of employment with C&A Industries, Inc. is entitled to the same rights to elect COBRA as an eligible dependent child of the covered employee. If You Have Questions Questions concerning your Plan or your COBRA 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. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA s website.) Keep Your Plan Informed of Address Changes In order to protect your family s rights, you should keep C&A Industries, Inc. informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to C&A Industries, Inc. Plan Contact Information You may obtain information about the Plan and COBRA coverage on request from: Brenda Royle, Benefits Director C&A Industries, Inc. 13609 California Street Omaha, NE 68154 402.891.0009 The contact information for the Plan may change from time to time. The most recent information will be included in the Plan s most recent summary plan description (if you do not have a copy, you may request one from C&A Industries, Inc.).
Notice of Qualifying Event (Form & Notice Procedures) NOTICE OF QUALIFYING EVENT (Form & Notice Procedures) C&A Industries, Inc. This form (including the Notice Procedures for Notice of Qualifying Event appearing at the end of this form) is part of the Plan s COBRA initial notice. For more information about this form, the Plan s notice procedures, and your COBRA rights and obligations, consult the Plan s summary plan description and the other provisions of the Plan s COBRA initial/general notice. (You may obtain copies of these documents from C&A Industries, Inc.) When to Use this Form: Use this form when any of the following events (qualifying events) occurs: A spouse covered under the Plan becomes divorced or legally separated from the covered employee; The covered employee reduced or eliminated his or her spouse s Plan coverage in anticipation of their divorce or legal separation, and the anticipated divorce or legal separation has subsequently occurred; or A child covered under the Plan ceases to be a dependent under the terms of the Plan. Deadline: The deadline for providing this Notice of Qualifying Event is 60 days after the later of (1) the qualifying event; and (2) the date on which the covered spouse or dependent child would lose coverage under the terms of the Plan as a result of the qualifying event. Notice Procedures: You must follow the Notice Procedures for Notice of Qualifying Event appearing at the end of this form. Warning: If your notice is late, or if it is not completed and provided to C&A Industries, Inc. as described in the Notice Procedures for Notice of Qualifying Event appearing at the end of this form, no qualified beneficiary will be offered the opportunity to elect COBRA coverage.
Complete this portion: Notice of Qualifying Event (Form & Notice Procedures) Identify the Covered Employee (the employee or former employee who is or was covered under the Plan): Print name of employee Address Event Description (Check one and complete): Qualifying Event Employee and spouse: (check one) divorced legally separated Print name of the spouse: Address of spouse: Date of divorce or legal separation: Is a copy of the decree of divorce or legal separation enclosed with this notice? Yes No If the spouse s coverage was reduced or eliminated, and later a divorce or legal separation occurred, is evidence that the spouse s Plan coverage was eliminated or reduced in anticipation of the divorce or legal separation enclosed with this notice? Yes No N/A Qualifying Event Employee s child ceased to be an eligible dependent under the Plan Print name of child: Address of child: same as employee s address different address (provide address) Reason child ceased to be eligible dependent (check one): attained age lost student status married other (explain) Date of event causing loss of dependent eligibility: Certification, Signature, and Date: I certify that the above information is true and correct. I am the (check one): employee or former employee spouse or former spouse former dependent child other (explain) Signature Date Print Name Address Telephone Number --------------------------------------------------------------------------------------------------------------------- For Plan Use Only: Date Notice of Qualifying Event received: Date of postmark, if mailed: Divorce decree enclosed? Yes No N/A Decree of legal separation enclosed? Yes No N/A Satisfactory evidence that elimination or reduction of coverage was in anticipation of divorce or legal separation? Yes No N/A
Notice of Qualifying Event (Form & Notice Procedures) Notice Procedures for Notice of Qualifying Event How to Provide Notice of Qualifying Event You must mail or hand deliver this notice to: Brenda Royle, Benefits Director C&A Industries, Inc. 13609 California Street Omaha, NE 68154 402.891.0009 This contact information may change from time to time. The most recent contact information will be included in the Plan s most recent summary plan description (if you do not have a copy, you may request one from C&A Industries, Inc.). Your notice must be in writing (using this form) and must be mailed or handdelivered. Oral notice, including notice by telephone, is not acceptable. Electronic (including emailed or faxed) notices are not acceptable. If mailed, your notice must be postmarked no later than the deadline described on the first page of this Notice of Qualifying Event form. If hand-delivered, your notice must be received by the individual at the address specified above no later than the deadline described on the first page of this form. Required Form and Information for Notice of Qualifying Event You must use this form of Notice of Qualifying Event to notify C&A Industries, Inc. of a qualifying event (i.e., the divorce or legal separation or a child s loss of dependent status), and all of the applicable items on the form must be completed. If you are notifying C&A Industries, Inc. of a divorce or legal separation, your notice must include a copy of the decree of divorce or legal separation. If your coverage is reduced or eliminated and later a divorce or legal separation occurs, and you are notifying C&A Industries, Inc. that your Plan coverage was reduced or eliminated in anticipation of the divorce or legal separation, you must provide notice within 60 days of the divorce or legal separation in accordance with these Notice Procedures for Notice of Qualifying Event and must in addition provide evidence satisfactory to C&A Industries, Inc. that your coverage was reduced or eliminated in anticipation of the divorce or legal separation. Incomplete Notice of Qualifying Event If you provide a written notice that does not contain all of the information and documentation required by these Notice Procedures for Notice of Qualifying Event, such a notice will nevertheless be considered timely if all of the following conditions are met: the notice is mailed or hand-delivered to the individual and address specified above; the notice is provided by the deadline described on the first page of this form; from the written notice provided, C&A Industries, Inc. is able to determine that the notice relates to the Plan; from the written noticed provided, C&A Industries, Inc. is able to identify the covered employee and qualified beneficiary(ies), the qualifying event (the divorce, legal separation, or child s loss of dependent status), and the date on which the qualifying event occurred; and the notice is supplemented in writing with the additional information and documentation necessary to meet the Plan s requirements (as described in these Notice Procedures for Notice of Qualifying Event) within 15 business days after a written or oral request from C&A Industries, Inc. for more information (or, if later, by the deadline for this Notice of Qualifying Event described on the first page of this form).
Notice of Qualifying Event (Form & Notice Procedures) If any of these conditions is not met, the incomplete notice will be rejected and COBRA will not be offered. If all of these conditions are met, the Plan will treat the notice as having been provided on the date that the Plan receives all of the required information and documentation but will accept the notice as timely. Who May Provide Notice of Qualifying Event The covered employee (i.e., the employee or former employee who is or was covered under the Plan), a qualified beneficiary with respect to the qualifying event, or a representative acting on behalf of either may provide the notice. A notice provided by any of these individuals will satisfy any responsibility to provide notice on behalf of all qualified beneficiaries who lost coverage due to the qualifying event described in the notice. Additional Evidence of Date of Qualifying Event May Be Required If your notice was regarding a child s loss of dependent status, you must, if C&A Industries, Inc. requests it, provide documentation of the date of the qualifying event that is satisfactory to C&A Industries, Inc. (for example, a birth certificate to establish the date that a child reached the limiting age, a marriage certificate to establish the date that a child married, or a transcript showing the last date of enrollment in an educational institution). This will allow C&A Industries, Inc. to determine if you gave timely notice of the qualifying event and were consequently entitled to elect COBRA. If you do not provide satisfactory evidence within 15 business days after a written or oral request from C&A Industries, Inc. that the child ceased to be a dependent on the date specified in your Notice of Qualifying Event, his or her COBRA coverage may be terminated (retroactively if applicable) as of the date that COBRA coverage would have started. C&A Industries, Inc. will require repayment to the Plan of all benefits paid after the termination date.
Notice of Disability (Form & Notice Procedures) NOTICE OF DISABILITY (Form & Notice Procedures) C&A Industries, Inc. This form (including the Notice Procedures for Notice of Disability appearing at the end of this form) is part of the Plan s COBRA initial notice and also part of the Plan s COBRA election notice (for 18-month qualifying events). For more information about this form, the Plan s notice procedures, and your COBRA rights and obligations, consult the Plan s summary plan description and the other provisions of the Plan s COBRA initial/general notice and election notice (for 18-month qualifying events). (You may obtain copies of these documents from C&A Industries, Inc.) When to Use this Form: Use this form when the Social Security Administration has determined that a qualified beneficiary was disabled on any day of the first 60 days following a qualifying event that was the covered employee s termination of employment or reduction of hours. (Note: If the Social Security Administration made the disability determination before the covered employee s termination of employment or reduction of hours, you may still use this form to report the earlier disability determination, so long as the qualified beneficiary remains disabled and you provide this Notice of Disability by the deadline described below.) Deadline: The deadline for providing this Notice of Disability is 60 days after the latest of (1) the date of the Social Security Administration s disability determination; (2) the date of the covered employee s termination of employment or reduction of hours; and (3) the date on which the qualified beneficiary would lose coverage under the terms of the Plan as a result of the termination of employment or reduction of hours. Your notice of Disability must also be provided within 18 months after the covered employee s termination of employment or reduction of hours. form. Notice Procedures: You must follow the Notice Procedures for Disability appearing at the end of this Warning: If your notice is late, or if it is not completed and provided to C&A Industries, Inc. as described in the Notice Procedures for Notice of Disability appearing at the end of this form, no extended COBRA coverage will be available to any qualified beneficiary.
Complete this portion: Notice of Disability (Form & Notice Procedures) Identify the Covered Employee (the employee or former employee who is or was covered under the Plan): Print name of employee Address of employee Identify Initial Qualifying Event (the event that started your COBRA coverage) (Check one and complete): Termination of Employment Reduction of hours Date of initial qualifying event: Identify All Qualified Beneficiaries: Print name(s) of all qualified beneficiaries who lost coverage due to the initial qualifying event and who are still receiving COBRA coverage now: Address of each qualified beneficiary (check one) same as employee s address different address (provide address) Social Security Administration s Determination of Disability: Date of Social Security Administration s determination: Is a copy of the Social Security Administration s determination enclosed with this notice? Yes No Date that disabled qualified beneficiary became disabled (according to Social Security Administration determination): Has the Social Security Administration subsequently determined that the qualified beneficiary is no longer disabled? Yes No Certification, Signature, and Date: I certify that the above information is true and correct. I am the (check one): employee or former employee spouse or former spouse disabled qualified beneficiary other (explain) Signature Date Print Name Address Telephone Number --------------------------------------------------------------------------------------------------------------------- For Plan Use Only: Date Notice of Disability received: Date of postmark, if mailed: Social Security Administration determination of disability enclosed? Yes No
Notice of Disability (Form & Notice Procedures) Notice Procedures for Notice of Disability How to Provide Notice of Disability You must mail or hand deliver this notice to: Brenda Royle, Benefits Director C&A Industries, Inc. 13609 California Street Omaha, NE 68154 402.891.0009 This contact information may change from time to time. The most recent contact information will be included in the Plan s most recent summary plan description (if you do not have a copy, you may request one from C&A Industries, Inc.). Your notice must be in writing (using this form) and must be mailed or handdelivered. Oral notice, including notice by telephone, is not acceptable. Electronic (including emailed or faxed) notices are not acceptable. If mailed, your notice must be postmarked no later than the deadline described on the first page of this Notice of Disability form. If handdelivered, your notice must be received by the individual at the address specified above no later than the deadline described on the first page of this form. Required Form and Information for Notice of Disability You must use this form of Notice of Disability to notify C&A Industries, Inc. of a qualified beneficiary s disability, and all of the applicable items on the form must be completed. Your notice of Disability must include a copy of the Social Security Administration s determination of disability. Incomplete Notice of Disability If you provide a written notice to C&A Industries, Inc. that does not contain all of the information and documentation required by these Notice Procedures for Notice of Disability, such a notice will nevertheless be considered timely if all of the following conditions are met: the notice is mailed or hand-delivered to the individual and address specified above; the notice is provided by the deadline described on the first page of this form; from the written notice provided, C&A Industries, Inc. is able to determine that the notice relates to the Plan and a qualified beneficiary s disability; from the written noticed provided, C&A Industries, Inc. is able to identify the covered employee and qualified beneficiary(ies), the covered employee s termination of employment or reduction of hours occurred; and the notice is supplemented in writing with the additional information and documentation necessary to meet the Plan s requirements (as described in these Notice Procedures for Notice of Disability) within 15 business days after a written or oral request from C&A Industries, Inc. for more information (or, if later, by the deadline for this Notice of Disability described on the first page of this form). If any of these conditions is not met, the incomplete notice will be rejected and COBRA will not be extended. If all of these conditions are met, the Plan will treat the notice as having been provided on the date that the Plan receives all of the required information and documentation but will accept the notice as timely.
Notice of Disability (Form & Notice Procedures) Who May Provide Notice of Disability The covered employee (i.e., the employee or former employee who is or was covered under the Plan), a qualified beneficiary who lost coverage due to the covered employee s termination or reduction of hours and is still receiving COBRA coverage, or a representative acting on behalf of either may provide the notice. A notice provided by any of these individuals will satisfy any responsibility to provide notice on behalf of all qualified beneficiaries who may be entitled to an extension of the maximum COBRA coverage period due to the disability reported in the notice.
Notice of Second Qualifying Event (Form & Notice Procedures) NOTICE OF SECOND QUALIFYING EVENT (Form & Notice Procedures) C&A Industries, Inc. This form (including the Notice Procedures for Notice of Second Qualifying Event appearing at the end of this form) is part of the Plan s COBRA initial notice and also part of the Plan s COBRA election notice (for 18-month qualifying events). For more information about this form, the Plan s notice procedures, and your COBRA rights and obligations, consult the Plan s summary plan description and the other provisions of the Plan s COBRA initial/general notice and election notice (for 18-month qualifying events). (You may obtain copies of these documents from C&A Industries, Inc.) When to Use this Form: Use this Notice of Second Qualifying Event when any of the following events (second qualifying events) occurs: A spouse who is receiving COBRA coverage becomes divorced or legally separated from the covered employee; A child who is receiving COBRA coverage ceases to be a dependent under the terms of the Plan; or The covered employee dies while one or more qualified beneficiaries are receiving COBRA coverage. Deadline: The deadline for providing this Notice of Second Qualifying Event is 60 days after the later of (1) the date of the second qualifying event; and (2) the date on which the covered spouse or dependent child would lose coverage under the terms of the Plan as a result of the second qualifying event (if this event had occurred while the qualified beneficiary was still covered under the Plan). Notice Procedures: You must follow the Notice Procedures for Notice of Second Qualifying Event appearing at the end of this form. Warning: If your notice is late, or if it is not completed and provided to C&A Industries, Inc. as described in the Notice Procedures for Notice of Second Qualifying Event appearing at the end of this form, no extended COBRA coverage will be available to any qualified beneficiary.
Notice of Second Qualifying Event (Form & Notice Procedures) Complete this portion: Identify the Employee Who Was Covered Under the Plan: Print name of employee: Address of employee: Identify Initial Qualifying Event (the event that started your COBRA coverage) (Check one and complete): Termination of Employment Reduction of hours Date of initial qualifying event: Identify All Qualified Beneficiaries: Print name(s) of all qualified beneficiaries who lost coverage due to the initial qualifying event and who are still receiving COBRA coverage now: Address of each qualified beneficiary (check one) same as employee s address different address (provide address) Identify Second Qualifying Event (Check one and complete): Second qualifying event Employee and spouse: (check one) divorced legally separated Print name of the spouse: Address of spouse: Date of divorce or legal separation: Is a copy of the decree of divorce or legal separation enclosed with this notice? Yes No Second qualifying event Employee s child ceased to be an eligible dependent under the Plan Print name of child: Address of child: same as employee s address different address (provide address) Reason child ceased to be eligible dependent (check one): attained age lost student status married other (explain) Date of event causing loss of dependent eligibility: Second qualifying event Death of covered employee Date of employee s death:
Notice of Second Qualifying Event (Form & Notice Procedures) Certification, Signature, and Date: I certify that the above information is true and correct. I am the (check one): employee or former employee spouse or former spouse former dependent child other (explain) Signature Date Print Name Address Telephone Number --------------------------------------------------------------------------------------------------------------------- For Plan Use Only: Date Notice of Qualifying Event received: Date of postmark, if mailed: Decree of divorce or legal separation enclosed? Yes No N/A
Notice of Second Qualifying Event (Form & Notice Procedures) Notice Procedures for Notice of Second Qualifying Event How to Provide Notice of Second Qualifying Event You must mail or hand deliver this notice to: Brenda Royle, Benefits Director C&A Industries, Inc. 13609 California Street Omaha, NE 68154 402.891.0009 This contact information may change from time to time. The most recent contact information will be included in the Plan s most recent summary plan description (if you do not have a copy, you may request one from C&A Industries, Inc.). Your notice must be in writing (using this form) and must be mailed or handdelivered. Oral notice, including notice by telephone, is not acceptable. Electronic (including emailed or faxed) notices are not acceptable. If mailed, your notice must be postmarked no later than the deadline described on the first page of this Notice of Second Qualifying Event form. If hand-delivered, your notice must be received by the individual at the address specified above no later than the deadline described on the first page of this form. Required Form and Information for Notice of Second Qualifying Event You must use this form of Notice of Second Qualifying Event to notify C&A Industries, Inc. of a second qualifying event (i.e., a divorce or legal separation, the covered employee s death, or a child s loss of dependent status), and all of the applicable items on the form must be completed. If you are notifying C&A Industries, Inc. of a divorce or legal separation, your notice must include a copy of the decree of divorce or legal separation. Incomplete Notice of Second Qualifying Event If you provide a written notice to C&A Industries, Inc. that does not contain all of the information and documentation required by these Notice Procedures for Notice of Second Qualifying Event, such a notice will nevertheless be considered timely if all of the following conditions are met: the notice is mailed or hand-delivered to the individual and address specified above; the notice is provided by the deadline described on the first page of this form; from the written notice provided, C&A Industries, Inc. is able to determine that the notice relates to the Plan; from the written noticed provided, C&A Industries, Inc. is able to identify the covered employee and qualified beneficiary(ies), the first qualifying event (the covered employee s termination of employment or reduction of hours), the date on which the first qualifying event occurred, the second qualifying event, and the date on which the second qualifying event occurred; and the notice is supplemented in writing with the additional information and documentation necessary to meet the Plan s requirements (as described in these Notice Procedures for Notice of Second Qualifying Event) within 15 business days after a written or oral request from C&A Industries, Inc. for more information (or, if later, by the deadline for this Notice of Second Qualifying Event described on the first page of this form).
Notice of Second Qualifying Event (Form & Notice Procedures) If any of these conditions is not met, the incomplete notice will be rejected and COBRA will not be extended. If all of these conditions are met, the Plan will treat the notice as having been provided on the date that the Plan receives all of the required information and documentation but will accept the notice as timely. Who May Provide Notice of Second Qualifying Event The covered employee (i.e., the employee or former employee who is or was covered under the Plan), a qualified beneficiary who lost coverage due to the covered employee s termination or reduction of hours and is still receiving COBRA coverage, or a representative acting on behalf of either may provide the notice. A notice provided by any of these individuals will satisfy any responsibility to provide notice on behalf of all qualified beneficiaries who may be entitled to an extension of the maximum COBRA coverage period due to the second qualifying event reported in the notice. Additional Evidence of Date of Second Qualifying Event May Be Required If your notice was regarding a child s loss of dependent status, you must, if C&A Industries, Inc. requests it, provide documentation of the date of the qualifying event that is satisfactory to C&A Industries, Inc. (for example, a birth certificate to establish the date that a child reached the limiting age, a marriage certificate to establish the date that a child married, or a transcript showing the last date of enrollment in an educational institution). This will allow C&A Industries, Inc. to determine if you gave timely notice of the qualifying event and were consequently entitled to an extension of COBRA coverage. If you do not provide satisfactory evidence within 15 business days after a written or oral request from C&A Industries, Inc. that the child ceased to be a dependent on the date specified in your Notice of Second Qualifying Event, his or her COBRA coverage may be terminated (retroactively if applicable) as of the date that COBRA coverage would have ended without an extension due to the covered employee s death. C&A Industries, Inc. will require repayment to the Plan of all benefits paid after the termination date.