COBRA CONTINUATION COVERAGE ELECTION NOTICE
This notice contains important information about your right to continue your health care
coverage in the Michigan Technological University group health plan. Please read the
information contained in this notice very carefully.
To elect COBRA continuation coverage, follow the instructions on the next page to
complete the enclosed Election Form and submit it to us.
If you do not elect COBRA continuation coverage, your coverage under the Plan will end
on the last day of the month following your termination date due to:
End of Employment
Reduction in hours of employment
Death of Employee
Divorce or legal separation
Entitlement to Medicare Loss of dependent child status
Each person (“qualified beneficiary”) covered under the Plan at time of termination or
loss of eligibility is entitled to elect COBRA continuation coverage which will continue
group health care coverage under the Plan.
If you wish to continue the coverage, you must notify the Benefits Office within 60 days
from the receipt of this election notice. You will receive an invoice at the end of each
month from the accounting office. Please send your check or money order payable to
Michigan Technological University. Do not send any payment with the election form.
Your first billing may include more than one-month charge in order to avoid any lapse in
your coverage. Rates for COBRA continuation are included in this packet. Rates are
subject to change if there is a change in our health care coverage.
If you have any questions, please call the Benefits Office at 906-487-2517.
COBRA COVERAGE ELECTION FORM
INSTRUCTIONS: To elect COBRA, complete this Election Form and return to us.
Under federal law, you have 60 days after the date of this notice to decide whether you
want to elect COBRA under the Plan.
Send completed form to: Mic