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Date: August 12, 2017 From: LAZ Parking 15 Lewis Street Hartford, CT 06103 To: Lisa Gregorio Hunting Rd. Needham, MA 02494 All family members should read this notice carefully and retain for future reference. This notice applies to any employee, spouse and/or dependent child who was covered by the employer’s group health plan and lost coverage due to a qualifying event. Loss of coverage also includes an increase in the premium due to a qualifying event. Federal COBRA law allows a temporary extension of group health insurance coverage to qualified beneficiaries when coverage is lost due to the qualifying event listed below. YOUR PLAN OPTIONS, MONTHLY RATES, AND DUE DATES ARE: Plan Coverage Option Anthem MEDICAL Family Guardian DENTAL Family Event COBRA Coverages and Premiums Event Loss of Must Date Coverage Elect By Coverage Expires Premium Day Due End of Employment 8/20/2012 9/1/2012 11/1/2012 3/1/2013 $400.89 1st End of Employment 8/20/2012 9/1/2012 11/1/2012 3/1/2013 $27.21 1st An election is deemed to be made on the date the election is sent. If you do not send it before the last date to elect COBRA, you may lose the opportunity to elect. COBRA QUALIFIED BENEFICIARIES: Each employee, spouse and dependent child covered under the group health plan the day before the qualifying event is a qualified beneficiary and has independent election rights under COBRA. This means each qualified beneficiary may elect to continue coverages that were in place at the time of the qualifying event. COBRA qualified beneficiaries may also be allowed all options that active employees have under the plan, under the same terms and conditions as the active employees. If, during the COBRA coverage period, a child is born to or placed for adoption with the covered employee on COBRA, that child will be provided qualified beneficiary status if the child is enrolled on the plan. ELECTING COBRA COVERAGE: To elect COBRA, complete the enclosed election form and send it to Wentworth DeAngelis & Kaufman, Attn: Tammy Davis, 74 Batterson Park Rd, Farmington, CT 06032. Your COBRA election may be required to be made in writing. Generally, you will be removed form the group health plan during the election period. If COBRA is elected and paid for within the proper time frames, your coverage will reinstate without interruption from the date of the qualifying event after valid payment is made. If the employer/plan administrator allows you to sign a waiver regarding your continuation coverage, you may revoke the waiver during the election period. However, any claims incurred within the waiver period may not be covered. If you elect COBRA, your employer/plan administrator reserves the right to verify your eligibility and they reserve the right to terminate coverage retroactively if you are not eligible. COBRA may be denied based upon, but not limited to, termination of employment due to gross misconduct. If a qualified beneficiary is incapacitated, other specific individuals could elect on hi/her behalf by contacting the employer/plan administrator. HMO INFORMATION: If you participated in an HMO or walk-in clinic and used the provider’s services during the election period, the employer’s plan may allow the employer, at the employer’s option, to treat such a use as a constructive election. You would be obligated to pay any applicable charge for the coverage within 45 days of the constructive election. NO all employers may recognize constructive elections. HMOs may provide region-specific coverage. For a COBRA qualified beneficiary outside of the region, coverage may be reduced similarly to that of active employees outside of the region. In certain instances, coverage may be eliminated or provided for emergency service only. If the employer or plan administrator has a plan that would provide you coverage outside of the HMO region, this plan must be made available to you either on the date of your relocation or, if later, the first day of the month following your request for this coverage. Please refer to your insurance booklet for specific information. PREMIUM PAYMENTS: The employer may charge up to 102% of the applicable premium for COBRA. If you elect COBRA, you are allowed 45 days, which begins on the date your election is sent to pay for the premiums retroactive to the loss of coverage date. Checks must be made payable to LAZ Parking. You are allowed a minimum 30-day grace period on each monthly premium. Federal COBRA law does not require an additional grace period beyond the end of the 45-day period for payment of the retroactive premium. In some cases, a person may be removed from the plan in anticipation of a qualifying event (e.g., divorce or legal separation). In such cases, retroactive premiums may only be due to the event date (e.g., date of divorce or legal separation) rather than the loss of coverage date. The coverage the qualified beneficiary had at the time of the loss of coverage must be offered under COBRA. The employer/plan administrator is not required to provide coverage from the loss of coverage to the qualifying event date. Any claims made after your loss of coverage date may be held until you elect COBRA and all premiums are current. Failure to pay ANY premium will cause your coverage t be retroactively terminated. Premium payments may be made in monthly installments (including the retroactive payment). In some cases, COBRA premiums may be paid on a pre-tax basis under a Section 125 (cafeteria) plan established by the employer. Sending premium invoices is not required under COBRA law. It is your responsibility to pay premiums even in the absence of an invoice. COBRA EXTENSIONS: The 30-month period (for a termination or a reduction of hours) may be extended to a maximum of 36 months if another qualifying event (death of the employee, divorce or legal separation, employee’s Medicare entitlement or a dependent child ceasing to be a dependent) occurs during the original 18-month period. You need to notify the employer/plan administrator if you experience a second qualifying event and would like to extend your COBRA. Connecticut Public Act 10-13 extended the maximum continuation period for certain qualifying events from 18 months to 30 months. This change applies to individuals who are currently on state or federal COBRA continuation through coverage under a Connecticut group health insurance policy as well as to individuals covered under a Connecticut group health insurance policy who experience a qualifying event on May 5, 2010 or later. Please see the attached notice SUPPLEMENT to see if you qualify. DISABILITY INFORMATION: If any qualified beneficiary is deemed disable by the Social Security Administration (under Title II or XVI of the Social Security Act) prior to or within the first 60 days of COBRA, all qualified beneficiaries may be eligible to extend their COBRA up to 29 months from the date of the termination or reduction of hours. To receive this COBRA extension, you must notify the employer/plan administrator of the disability determination before the 18 months expires and within 60 days of the determination letter. If the disabled qualified beneficiary is deemed no longer disabled, you need to notify the employer/plan administrator within 30 days of that determination. If deemed no longer disabled, all qualified beneficiaries are no longer eligible for the additional 11 months of COBRA and coverage will end the month that begins 30 days after the date of the final determination. Up to 150% of the applicable premium could be charged for this extension of COBRA from the 19 th through the 29th month, if the disabled qualified beneficiary is part of the extension. REASONS COBRA COULD TERMINATE EARLY: 1. 2. 3. 4. 5. The employer no longer provides any group health coverage to any employee. Any COBRA premium is no paid by the grace date. After the date you elect COBRA, you become covered under another group health plan that; Does not contain any exclusion or limitation with respect to any pre-existing condition that applies to you. Has pre-existing condition limitation that do not apply to you. Has pre-existing condition clauses that apply to you, which you have satisfied After the date you elect COBRA, you become entitled to Medicare (actually enrolled, not just eligible). If the Qualified Beneficiary is no longer deemed disabled by Social Security, coverage will terminate the first of the month that is more than 30 days after the date of the final determination. COBRA continuation coverage may be retroactively terminated for cause (e.g., fraudulent activity) on the same basis that the plan terminates the coverage of a similarly situated active employee for cause. Health FSAs (Section 125 or cafeteria plans) may have a separate, earlier expiration date. INDIVIDUAL CONVERSION OPTION: You may be eligible to elect an individual conversion option if your plan has such an option. Conversion coverage is not the same as group health coverage; rates and coverages may be different. For more information, read your insurance booklet or Summary Plan Description, or contact the employer/plan administrator. RETIREE COVERAGE AND COBRA: If you are covered by a retiree plan offered by the employer/plan administrator and you lose that retiree coverage due to a COBRA qualifying event, your coverage may be extended under COBRA. Contact the employer/plan administrator for further information. PLAN INFORMATION: For detailed plan information, please refer to your insurance booklet. Your “insurance booklet” may be referred to as a Summary Plan Description (SPD), benefits booklet or Certificate of Coverage which may be available by contacting the employer/plan administrator listed above. The information contained in the insurance booklet may not be altered by any statements made by representatives of the employer/plan administrator. Some states also have health insurance continuation rules. Please check your insurance booklet for further information regarding specific state continuation laws that may apply to you. WHY SHOULD I ELECT COBRA?: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) created creditable coverage, which includes COBRA. Creditable coverage may impact a preexisting condition exclusion period on another health plan. Under HIPAA, employers and carriers are required to count creditable coverage towards a preexisting condition exclusion period, thus reducing the time a preexisting condition is not covered, as long as you do not exceed 63 days without creditable coverage. By electing COBRA, you may reduce the possibility of a gap in coverage and the preexisting condition exclusion period under another plan. If you fail to timely elect and pay for COBRA, you may experience a gap in your insurance coverage and may not be able to use your previous health insurance as a credit towards a preexisting condition limitation or exclusion. Date: August 12, 2017 From: LAZ Parking 15 Lewis Street Hartford, CT 06103 To: Lisa Gregorio Hunting Rd. Needham, MA 02494 COBRA CONTINUATION COVERAGE ELECTION FORM If the address above is incorrect, please make the appropriate change. If you are making an address change, also please notify your former employer and carriers of this change. COBRA Coverages and Premiums Event Loss of Must Date Coverage Elect By Plan Coverage Option Event Anthem MEDICAL Family Guardian DENTAL Family End of Employment 8/20/2012 9/1/2012 End of Employment 8/20/2012 9/1/2012 Coverage Expires Premium Day Due 11/1/2012 3/1/2013 $400.89 1st 11/1/2012 3/1/2013 $27.21 1st LIST PERSON(S) ELECTING COBRA: All qualified beneficiaries have independent election rights. First Name Last Name SS# Coverage Desired Birth Date ______________________ ______________________________ ______________________ ______________________ ___/___/___ ______________________ ______________________________ ______________________ ______________________ ___/___/___ ______________________ ______________________________ ______________________ ______________________ ___/___/___ ______________________ ______________________________ ______________________ ______________________ ___/___/___ I/We understand that my/our COBRA coverage may be retroactively terminated if I /we misrepresent any facts on this election form or any other insurance document. I/we hereby apply for COBRA coverage for myself and/or the individuals listed on this form. I/we understand that all retroactive premiums are due within 45 days of the date I/we elect and that I/we elect and that premium payments may be made in monthly installments. I/we understand that the employer/plan administrator is not required to provide billing statements. _____________________________________________________ Signature (Please copy this form for your records.) Return the completed form and payment to: _________________ Date _____________________ Daytime Phone Number Wentworth, DeAngelis & Kaufman ATTN: Tammy Davis 74 Batterson Park Rd Farmington, CT 06032 CARRIER NOTE: This form is an individual written request for you to provide the same coverage to qualified beneficiaries that you provide to active employees (TAMRA 1988). Connecticut Continuation Coverage Notice SUPPLEMENT For use by group health insurers and group policyholders for qualified beneficiaries enrolled in Continuation Coverage on May 5, 2010 or who experience a qualifying event on May 5, 2010 or later Date of Notice: August 12, 2017 Dear: Lisa Gregorio (Name of Qualified Beneficiary(ies) This notice contains important information about your right to continue your group health insurance coverage for up to 30 months with LAZ Parking (the Plan). (Name of Group Health Plan) THIS SUPPLEMENT IS BEING DISTRIBUTED TO YOU TO CONFIRM YOUR PLAN’S COMPLIANCE WITH CONNECTICUT PUBLIC ACT 10-13 Please read the information contained in this notice carefully Connecticut Public Act 10-13 extended the maximum continuation period for certain qualifying events from 18 months to 30 months. This change applies to individuals who are currently on state or federal COBRA continuation through coverage under a Connecticut group health insurance policy as well as to individuals covered under a Connecticut group health insurance policy who experience a qualifying event on May 5, 2010 or later. You are receiving this notice because either: (1) you are currently on continuation coverage as of May 5, 2010 (effective date of new law and your 18 month continuation period did not expire prior to May 5, 2010), or (2) you have experienced a qualifying event on May 5, 2010 or later. If your loss of health coverage was due to a lay-off, termination of employment (except for gross misconduct), leave of absence or reduction in hours, you are eligible for extended continuation coverage up to 30 months, from the beginning date of your continuation coverage, provided you meet the other applicable provisions, including paying premiums on a timely basis. If you have any questions, please contact your COBRA administrator.