In the case of a divorce, death, a Dependent child ceasing to be a Dependent, or other “qualifying event” that causes or would cause a loss of Plan coverage, the Participant must notify the Administrative Office within 60 days of when the event occurs to preserve rights to elect continuing Plan coverage. Eligible Employees and Retired Participants are liable to repay Plan benefits paid on behalf of an individual who is no longer their Dependent.

This notice must be provided in writing to the Administrative Office (contact information in the Quick Reference Table at the front of this booklet). Your written notice should describe the qualifying event, the date of the qualifying event, the affected employee’s name and any dependents’ name(s) and addresses. If the qualifying event is divorce, you should include a certified copy of your divorce decree. If the qualifying event is a dependent’s loss of eligibility for coverage as a Dependent, you should include a written explanation of the reason for the loss of Dependent status. You may send your written notice and supporting documentation by mail, hand delivery, or overnight courier. If you use the mail, your envelope must be postmarked by no later than the 60-day deadline specified above. If you hand deliver your notice and documentation, it must be received by an authorized individual at the address specified above by no later than the 60-day deadline. If you use an overnight courier (such as UPS), your notice must be delivered to the courier for shipment (as reflected on the delivery order) no later than the 60-day deadline specified above. Other types of notice, such as faxes, electronic notice (including email notice) and oral notice (including notice by telephone) are not acceptable. If your written notice and supporting documentation is not mailed, delivered by hand, or sent by overnight courier as specified above to the Administrative Office within the 60-day period, you and/or your family members will lose the right to elect COBRA.