CONNECTICUT CARPENTERS HEALTH FUND COBRA CONTINUATION COVERAGE ELECTION NOTICE

CONNECTICUT CARPENTERS HEALTH FUND COBRA CONTINUATION COVERAGE ELECTION NOTICE DATE Dear : This ntice cntains imprtant infrmatin abut yur right t cntinue yur health care cverage in the Cnnecticut Carpenters Health Fund (the Plan), as well as ther health cverage ptins that may be available t yu, including cverage thrugh the federal Health Insurance Marketplace (www.healthcare.gv r call 1-800-318-2596) r Cnnecticut s Marketplace, knwn as Access Health CT (www.accesshealthct.cm r call 1-855-805-HEAL/1-855-805-4325). This ntice applies t everyne in the family wh is cvered by the Plan. Yu may be able t get cverage thrugh either the Health Insurance Marketplace r Cnnecticut s Marketplace that csts less than COBRA cntinuatin cverage. Please read the infrmatin cntained in this ntice very carefully befre yu make yur decisin. T elect COBRA cntinuatin cverage, fllw the instructins n the next page t cmplete the enclsed Electin Frm and submit it t us. If yu d nt elect COBRA cntinuatin cverage, yur cverage under the Plan ended n due t: End f emplyment Death f Member Lss f Eligible Dependent child status Reductin in hurs f emplyment Divrce r legal separatin Each persn ( qualified beneficiary ) in the categry(ies) checked belw has an independent right t elect COBRA cntinuatin cverage, which will cntinue grup health care cverage under the Plan fr up t 36 mnths: Member r frmer Member Member s Spuse Frmer Spuse lsing cverage due t divrce Dependent child(ren) cvered under the Plan n the day befre the event that caused the lss f cverage Child wh is lsing cverage under the Plan because s/he is n lnger an Eligible Dependent under the Plan If elected, COBRA cntinuatin cverage will begin n and may last until. There is nly ne plan f benefits available, which includes medical, dental, prescriptin drug, visin, and memberassistance benefits. It des nt include life insurance, accidental death and dismemberment, r weekly disability incme. COBRA cntinuatin cverage cst is $1,265.00 per mnth n matter hw many eligible family members chse t cntinue cverage. That cst may be changed nce a year. Yu d nt have t send any payment with the Electin Frm. Imprtant additinal infrmatin abut payment fr COBRA cntinuatin cverage and ther health cverage alternatives is included in the pages fllwing the Electin Frm. Whether r nt yu elect COBRA cntinuatin cverage, each persn in the categry(ies) checked abve may have an independent right t cnvert up t $10,000 f any life insurance the Health Fund prvides thrugh its grup plicy with Aetna t an individual plicy. The deadline fr this cnversin is very shrt 45 days after lss f 00228.001/602442.3 1

cverage fr active members and 31 days after lss f cverage fr retirees. Please call Aetna at 1-800-523-5065 t find ut the rates and hw t apply. If yu need assistance with life insurance cnversin, call the Fund Office. If yu have any questins abut this ntice r yur rights t COBRA cntinuatin cverage, yu shuld cntact Ms. Debrah L. Palmieri, Health Fund Administratr, Cnnecticut Carpenters Health Fund, 10 Bradway, Hamden, CT 06518, (800) 922-6026 (tll-free). 00228.001/602442.3 2

CONNECTICUT CARPENTERS HEALTH FUND COBRA CONTINUATION COVERAGE ELECTION FORM INSTRUCTIONS: T elect COBRA cntinuatin cverage, yu must cmplete this Electin Frm and return it t us by the. This Electin Frm must be cmpleted and returned by mail, fax r hand-delivery. If mailed, it must be pst-marked n later than the due date. Under federal law, yu must have 60 days after the date we send yu this Electin Frm t decide whether yu want t elect COBRA cntinuatin cverage under the Plan. Remember: Each qualified beneficiary has an independent right t elect cntinuatin cverage, the Member r the Member s spuse may elect cntinuatin cverage n behalf f all ther qualified beneficiaries with respect t the qualifying event, and a parent r legal guardian may elect cntinuatin cverage n behalf f a minr child. Send r deliver the cmpleted Electin Frm t: Ms. Debrah L. Palmieri, Cnnecticut Carpenters Health Fund, 10 Bradway, Hamden, CT 06518; facsimile (203) 288-3235. If yu d nt submit a cmpleted Electin Frm by the due date, yu will lse yur right t elect COBRA cntinuatin cverage and yu will nt have any cverage under the Plan after the date yur active cverage ends. If yu reject COBRA cntinuatin cverage befre the due date, yu may change yur mind as lng as yu furnish a cmpleted Electin Frm befre the due date. Hwever, if yu change yur mind after first rejecting COBRA cntinuatin cverage, yur COBRA cntinuatin cverage will begin n the date yu furnish the cmpleted Electin Frm t the Plan. Read the imprtant infrmatin abut yur rights and bligatins included in the pages after the Electin Frm. Check One: I am the Member r the Member s Spuse and I d nt wish t cntinue Cnnecticut Carpenters Health Fund cverage fr me, my spuse, r ur dependents. I (W e) elect COBRA cntinuatin cverage in the Cnnecticut Carpenters Health Fund as indicated belw: Name Date f Birth Relatinship t Member SSN (r ther identifier) a. b. c. Signature Print Name Print Address Date Relatinship t individual(s) listed abve Telephne Number 3

What is cntinuatin cverage? CONNECTICUT CARPENTERS HEALTH FUND IMPORTANT INFORMATION ABOUT YOUR COBRA CONTINUATION COVERAGE RIGHTS AND OTHER HEALTH COVERAGE ALTERNATIVES Federal law requires that mst grup health plans, including the Cnnecticut Carpenters Health Fund (the Plan ), give Members and their families the pprtunity t cntinue their health care cverage when there is a "qualifying event" that wuld result in a lss f cverage under an emplyer's plan. Depending n the type f qualifying event, "qualified beneficiaries" can include the Member (r retired Member) cvered under the grup health plan, the Member's spuse, and the Eligible Dependent children f the cvered Member. Cntinuatin cverage r COBRA cntinuatin cverage is the same cre cverage that the Plan gives t ther Members r beneficiaries under the Plan wh are nt receiving cntinuatin cverage. Each qualified beneficiary wh elects cntinuatin cverage will have the same rights under the Plan as ther Members r beneficiaries cvered under the Plan, including special enrllment rights. Are there ther cverage ptins besides COBRA cntinuatin cverage? Yes. Instead f enrlling in COBRA cntinuatin cverage, there may be ther mre affrdable cverage ptins fr yu and yur family thrugh the federal Health Insurance Marketplace, Cnnecticut s Marketplace, Medicaid, r ther grup health plan cverage ptins (such as a spuse s plan) thrugh what is called a special enrllment perid. Sme f these ptins may cst less than COBRA cntinuatin cverage thrugh the Fund. Yu shuld cmpare yur ther cverage ptins with COBRA cntinuatin cverage and chse the cverage that is best fr yu. Fr example, if yu mve t ther cverage yu may pay mre ut f pcket than yu wuld under COBRA because the new cverage may impse a new deductible. When yu lse jb-based health cverage (due t the end f emplyment r a reductin in hurs f emplyment), it s imprtant that yu chse carefully between COBRA cntinuatin cverage and ther cverage ptins, because nce yu ve made yur chice, it can be difficult r impssible t switch t anther cverage ptin. If I elect COBRA cntinuatin cverage hw lng will cntinuatin cverage last? In the case f a lss f cverage due t the end f emplyment r a reductin in hurs f emplyment, cverage generally may be cntinued fr up t a ttal f 18 mnths. In the case f lsses f cverage due t a Member's death, divrce r curt-rdered legal separatin, r a dependent child ceasing t be an Eligible Dependent under the terms f the Plan, cverage may be cntinued fr up t a ttal f 36 mnths. This ntice shws the maximum perid f cntinuatin cverage available t the qualified beneficiaries. Cntinuatin cverage will be terminated befre the end f the maximum perid if: any required mnthly cst is nt paid in full n time, a qualified beneficiary becmes cvered, after electing cntinuatin cverage, under anther grup health plan that des nt impse any pre-existing cnditin exclusin fr a pre-existing cnditin f the qualified beneficiary, a qualified beneficiary becmes entitled t Medicare benefits (under Part A, Part B, r bth) after electing cntinuatin cverage, the Plan is terminated, 4

the Member engages in any emplyment r wnership in a nn-unin cmpany in the carpentry industry, r the Member, Spuse r Eligible Dependent prvides any false r misleading infrmatin, r withhlds any infrmatin, which causes benefits t be prvided under the Plan t smene nt therwise entitled t benefits, in the case f extended cverage due t disability, the Scial Security Administratin makes a final determinatin that the individual is n lnger disabled, r the Emplyer that emplyed the Member prir t the qualifying event has stpped cntributing t the Fund but is making grup health care cverage available thrugh anther plan. If the Trustees amend, reduce, r terminate any part f the Plan s benefits, COBRA cntinuatin cverage will nly prvide benefits still ffered under the Plan. Hw can yu extend the length f COBRA cntinuatin cverage beynd 18 mnths? If yu elect cntinuatin cverage due t the end f emplyment r a reductin in hurs, an extensin f the 18- mnth maximum perid f cverage may be available if a qualified beneficiary is disabled r a secnd qualifying event ccurs. Yu must ntify Ms. Debrah L. Palmieri, Health Fund Administratr, f a disability r a secnd qualifying event in rder t extend the perid f cntinuatin cverage. Yu must use the Fund s Member/Qualified Beneficiary Ntice f Qualifying Event frm, available by cntacting the Administratr r dwnlading frm the Fund s website. Failure t prvide timely ntice f a disability r secnd qualifying event will eliminate the right t extend the perid f cntinuatin cverage. Disability An 11-mnth extensin f cverage (after the initial 18-mnth perid) may be available if any f the qualified beneficiaries is determined by the Scial Security Administratin (SSA) t be disabled. The disability has t have started at sme time within the first 60 days f COBRA cntinuatin cverage and must last at least until the end f the 18-mnth perid f cntinuatin cverage. Yu must ntify the Plan within 60 days after the ntice was received by a qualified beneficiary and befre the end f the initial 18-mnth perid. Each qualified beneficiary wh has elected cntinuatin cverage, and any child brn t, adpted by r placed with the cvered Member fr legal adptin during the initial 18-mnth perid, will be entitled t the 11-mnth disability extensin if ne f them qualifies. If the qualified beneficiary is determined by SSA t n lnger be disabled, yu must ntify the Plan f that fact within 30 days after SSA's determinatin. Secnd Qualifying Event An 18-mnth extensin f cverage will be available t spuses and dependent children wh elect cntinuatin cverage if a secnd qualifying event ccurs during the first 18 mnths f cntinuatin cverage. The maximum amunt f cntinuatin cverage available when a secnd qualifying event ccurs is 36 mnths frm the date f the first qualifying event. Such secnd qualifying events may include the death f a Member, divrce r separatin frm the Member, r a dependent child's ceasing t be eligible fr cverage as an Eligible Dependent under the Plan. These events can be a secnd qualifying event nly if they wuld have caused the qualified beneficiary t lse cverage under the Plan if the first qualifying event had nt ccurred. Yu must ntify the Plan within 60 days after a secnd qualifying event ccurs if yu want t extend yur cntinuatin cverage. Fr much mre infrmatin abut extending the length f COBRA cntinuatin cverage, yu are encuraged t visit the fllwing website: http://www.dl.gv/ebsa/publicatins/cbraemplyee.html. 5

Hw can yu elect COBRA cntinuatin cverage? T elect cntinuatin cverage, yu must cmplete the Electin Frm and furnish it accrding t the directins n the Frm. Each qualified beneficiary has a separate right t elect cntinuatin cverage. Fr example, the Member's Spuse may elect cntinuatin cverage even if the Member des nt. Cntinuatin cverage may be elected fr nly ne, several, r fr all dependent children wh are qualified beneficiaries. A parent may elect t cntinue cverage n behalf f any eligible dependent children. The Member r the Member's Spuse can elect cntinuatin cverage n behalf f all f the qualified beneficiaries. If yu elect cntinuatin cverage and subsequently add a dependent (by marriage, birth, adptin, r placement fr adptin) during yur cverage perid, that new dependent can als be cvered fr the remainder f the cverage perid. Any qualified beneficiary can add a new spuse r child t his r her COBRA cntinuatin cverage; hwever, the newly added family members will nly have the rights f that qualified beneficiary. Yu must ntify the Fund Office f the additin f any new dependent within 30 days f the marriage, birth, adptin, r placement fr adptin. If, while yu are enrlled in cntinuatin cverage, yur Spuse r dependent lses cverage under anther grup health plan, yu may enrll the Spuse r dependent fr cverage fr the balance f the perid f COBRA cntinuatin cverage, but must d s within 30 days after the terminatin f the ther cverage. In cnsidering whether t elect cntinuatin cverage, yu shuld take int accunt that a failure t cntinue yur grup health cverage will affect yur future rights under federal law. First, yu can lse the right t avid having pre-existing cnditin exclusins applied t yu by ther grup health plans if yu have mre than a 63-day gap in health cverage, and electin f cntinuatin cverage may help yu nt have such a gap. Secnd, yu will lse the guaranteed right t purchase individual health insurance plicies that d nt impse such pre-existing cnditin exclusins if yu d nt get cntinuatin cverage fr the maximum time available t yu. Finally, yu shuld take int accunt that yu have special enrllment rights under federal law. Yu have the right t request special enrllment in anther grup health plan fr which yu are therwise eligible (such as a plan spnsred by yur spuse's emplyer) within 30 days after yur grup health cverage ends because f the qualifying event listed earlier. Yu will als have the same special enrllment right at the end f cntinuatin cverage if yu get cntinuatin cverage fr the maximum time available t yu. Hw much des COBRA cntinuatin cverage cst? Generally, each qualified beneficiary may be required t pay the entire cst f cntinuatin cverage. The amunt a qualified beneficiary may be required t pay may nt exceed 102 percent (r, in the case f an extensin f cntinuatin cverage due t a disability, 150 percent) f the cst t the grup health plan (including bth emplyer and emplyee cntributins) fr cverage f a similarly situated Member r beneficiary wh is nt receiving cntinuatin cverage. The required mnthly payment fr cntinuatin cverage is described n the first page f this Electin Ntice. The mnthly csts are generally fixed fr a 12-mnth perid, but are likely t change annually. When and hw must payment fr COBRA cntinuatin cverage be made? First payment fr cntinuatin cverage If yu elect cntinuatin cverage, yu d nt have t send any payment with the Electin Frm. Hwever, yu must make yur first payment fr cntinuatin cverage nt later than 45 days after the date f yur electin (this is the date the Electin Ntice is pst-marked, if mailed) and n benefits will be paid r cvered service prvided until yur payment is received. If yu d nt make yur first payment fr cntinuatin cverage in full within 45 days after the date f yur electin, yu will lse all cntinuatin cverage rights under the Plan. Yu are respnsible fr making 6

sure that the amunt f yur first payment is crrect. Yu may cntact Ms. Debrah L. Palmieri, Health Fund Administratr, at (800) 922-6026, extensin 602 (tll-free) t cnfirm the crrect amunt f yur first payment. Peridic payments fr cntinuatin cverage After yu make yur first payment fr cntinuatin cverage, yu will be required t make peridic payments fr each subsequent cverage perid. The amunt due fr each cverage perid is shwn n the first page f this Electin Ntice. The peridic payments can be made n a mnthly basis. Under the Plan, each f these peridic payments fr cntinuatin cverage is due n the 1 st day f each mnth fr that mnth. If yu make a peridic payment n r befre the first day f the cverage perid t which it applies, yur cverage under the Plan will cntinue fr that cverage perid withut any break. The Plan will send peridic ntices f payments due fr these cverage perids, althugh it reserves the right t discntinue that practice in the future. If yu d nt receive cupns r ther peridic ntices we send, yu still must make mnthly payments n time if yu wish yur COBRA cverage t cntinue. Grace perids fr peridic payments Althugh peridic payments are due n the 1st day f each mnth, yu will be given a grace perid until the last day f that mnth t make each peridic payment. Yur cntinuatin cverage will be prvided fr each cverage perid as lng as payment fr that cverage perid is made befre the end f the grace perid fr that payment. Hwever, if yu pay a peridic payment later than the first day f the mnth t which it applies, but befre the end f the grace perid fr the mnth, yur cverage under the Plan will be suspended as f the first day f the mnth and then retractively reinstated (ging back t the first day f the mnth) when the payment is received. This means that any claim yu submit fr benefits while yur cverage is suspended may be denied and may have t be resubmitted nce yur cverage is reinstated. If yu fail t make a mnthly payment befre the end f the grace perid fr that mnth, yu will lse all rights t cntinuatin cverage under the Plan. Remember: Yu cannt reinstate yur COBRA cntinuatin cverage nce it is terminated. Yur first payment and all peridic payments fr cntinuatin cverage shuld be sent t: Health Fund Administratr, Cnnecticut Carpenters Health Fund, 10 Bradway, Hamden, CT 06518. Checks shuld be made payable t Cnnecticut Carpenters Health Fund. What are the cnsequences fr failing t elect COBRA cntinuatin cverage? If yu fail t elect cntinuatin cverage, yu will nt be entitled t payment r reimbursement f any medical, drug, dental, visin r member-assistance benefits. If yu drp cverage, it culd affect yur legal rights in the future t transitin int anther grup health plan (this is smetimes called prtability ), t have guaranteed ability t purchase individual health cverage, and t add new family members t yur cverage (this is smetimes called special enrllment ). * * * * * * * * Yu may be able t get cverage thrugh the federal Health Insurance Marketplace (r fr Cnnecticut residents, Cnnecticut s Marketplace) that csts less than COBRA cntinuatin cverage. Yu can learn mre abut the Marketplace ptins belw. 7

What is the Health Insurance Marketplace? The Marketplace ffers ne-stp shpping t find and cmpare private health insurance ptins. In the Marketplace, yu culd be eligible fr a new kind f tax credit that lwers yur mnthly premiums and cstsharing reductins (amunts that lwer yur ut-f-pcket csts fr deductibles, cinsurance, and cpayments) right away, and yu can see what yur premium, deductibles, and ut-f-pcket csts will be befre yu make a decisin t enrll. Thrugh the Marketplace yu ll als learn if yu qualify fr free r lw-cst cverage frm Medicaid r the Children s Health Insurance Prgram (CHIP). Yu can access the Marketplace fr yur state at www.healthcare.gv. Als, if yu are a resident f Cnnecticut, yu have the ability t utilize Cnnecticut s Marketplace, which is Access Health CT. The cntact infrmatin fr Access Health CT is www.accesshealthct.cm, 1-855-805-HEAL (1-855-805-4325) / TTY: 1-855-789-2428. Cverage thrugh the Health Insurance Marketplace may cst less than COBRA cntinuatin cverage. Being ffered COBRA cntinuatin cverage wn t limit yur eligibility fr cverage r fr a tax credit thrugh the Marketplace. When can I enrll in Marketplace cverage? Yu always have 60 days frm the time yu lse jb-based health cverage t enrll in the Marketplace. That is because lsing jb-based health cverage is a special enrllment event. After 60 days yur special enrllment perid will end and yu may nt be able t enrll, s yu shuld take actin right away. In additin, during what is called an pen enrllment perid, anyne can enrll in Marketplace cverage. T find ut mre abut enrlling in the Marketplace, such as when the next pen enrllment perid will be and what yu need t knw abut qualifying events and special enrllment perids, visit www.healthcare.gv. Cnnecticut residents can als visit www.accesshealthct.cm. If I sign up fr COBRA cntinuatin cverage, can I switch t cverage in the Marketplace? What abut if I chse Marketplace cverage and want t switch back t COBRA cntinuatin cverage? If yu sign up fr COBRA cntinuatin cverage, yu can switch t a Marketplace plan during a Marketplace pen enrllment perid. Yu can als end yur COBRA cntinuatin cverage early and switch t a Marketplace plan if yu have anther qualifying event such as marriage r birth f a child thrugh smething called a special enrllment perid. But be careful thugh - if yu terminate yur COBRA cntinuatin cverage early withut anther qualifying event, yu ll have t wait t enrll in Marketplace cverage until the next pen enrllment perid, and culd end up withut any health cverage in the interim. Once yu ve exhausted yur COBRA cntinuatin cverage and the cverage expires, yu ll be eligible t enrll in Marketplace cverage thrugh a special enrllment perid, even if Marketplace pen enrllment has ended. If yu sign up fr Marketplace cverage instead f COBRA cntinuatin cverage, yu cannt switch t COBRA cntinuatin cverage under any circumstances. Can I enrll in anther grup health plan? Yu may be eligible t enrll in cverage under anther grup health plan (like a spuse s plan), if yu request enrllment within 30 days f the lss f cverage. 8

If yu r yur dependent chses t elect COBRA cntinuatin cverage instead f enrlling in anther grup health plan fr which yu re eligible, yu ll have anther pprtunity t enrll in the ther grup health plan within 30 days f lsing yur COBRA cntinuatin cverage. What factrs shuld I cnsider when chsing cverage ptins? When cnsidering yur ptins fr health cverage, we suggest that yu think abut: Premiums: Yur previus plan can charge up t 102% f ttal plan cst/premiums fr COBRA cverage. Other ptins, like cverage under a spuse s plan r thrugh the Marketplace, may be less expensive. Prvider Netwrks: If yu re currently getting care r treatment fr a cnditin, a change in yur health cverage may affect yur access t a particular health care prvider. Yu may want t check t see if yur current health care prviders participate in a specific netwrk as yu cnsider ptins fr health cverage. Drug Frmularies: If yu re currently taking medicatin, a change in yur health cverage may affect yur csts fr medicatin and in sme cases, yur medicatin may nt be cvered by anther plan. Yu may want t check t see if yur current medicatins are listed in drug frmularies fr ther health cverage. Service Areas: Sme plans limit their benefits t specific service r cverage areas s if yu mve t anther area f the cuntry, yu may nt be able t use yur benefits. Yu may want t see if yur plan has a service r cverage area, r ther similar limitatins. Other Cst-Sharing: In additin t premiums r cntributins fr health cverage, yu prbably pay cpayments, deductibles, cinsurance, r ther amunts as yu use yur benefits. Yu may want t check t see what the cst-sharing requirements are fr ther health cverage ptins, and whether thse ther ptins recgnize any cpayments, deductible, cinsurance and the like that yu and any family members incurred during yur mst recent cverage perid. Fr example, ne ptin may have much lwer mnthly premiums, but a much higher deductible and higher cpayments. Severance payments: If yu lst yur jb and received a severance package frm yur frmer emplyer, yur frmer emplyer may have ffered t pay sme r all f yur COBRA payments fr a perid f time. In this scenari, yu may want t cntact the Department f Labr at 1-866-444-3272 t discuss yur ptins. Fr mre infrmatin This ntice des nt fully describe cntinuatin cverage r ther rights under the Plan. Mre infrmatin abut cntinuatin cverage and yur rights under the Plan is available in yur summary plan descriptin r frm the Plan Administratr. Yu shuld send any ntices described in this Ntice r address any questins yu may have cncerning the infrmatin in this ntice r yur rights t cverage t: Ms. Debrah L. Palmieri, Health Fund Administratr, Cnnecticut Carpenters Health Fund, 10 Bradway, Hamden, CT 06518, (800) 922-6026, ext. 602 (tll-free). Fr mre infrmatin abut yur rights under ERISA, including COBRA, the Patient Prtectin and Affrdable Care Act, the Health Insurance Prtability and Accuntability Act (HIPAA), and ther laws affecting grup health plans, cntact the U.S. Department f Labr's Emplyee Benefits Security Administratin (EBSA) in yur area r visit the EBSA website at www.dl.gv/ebsa. (Addresses and phne numbers f Reginal and District EBSA 9

Offices are available thrugh EBSA's website.). Fr mre infrmatin abut health insurance ptins available thrugh the Health Insurance Marketplace r Cnnecticut s Marketplace, and t lcate an assister in yur area wh yu can talk t abut the different ptins, visit www.healthcare.gv r www.accesshealthct.cm. Keep Yur Plan Infrmed f Address Changes In rder t prtect yur and yur family's rights, yu shuld keep the Plan Administratr infrmed f any changes in yur address and the addresses f family members. Yu shuld als keep a cpy, fr yur recrds, f any ntices yu send t the Cnnecticut Carpenters Health Fund. 10