<p> CONTINUATION COVERAGE ELECTION NOTICE UNDER USERRA</p><p>Sample language for a Health Care Continuation Coverage Election Notice under USERRA (single-employer group health plans to be used in conjunction with COBRA Notice)</p><p>This notice contains important information about your right to continue health care coverage in [Name of group health care plan] (the plan) during a period of absence necessitated by service in the uniformed services. Please read the information contained in this notice carefully.</p><p>To elect continuation coverage, please complete the enclosed Election Form and submit it within [60 days] of the date of the notice to: [Contact information].</p><p>If you elect continuing coverage, coverage will begin on [Date employee’s absence for military service begins]. Coverage will end the earlier of:</p><p> a) [Date that is 24 months from the date coverage began], or</p><p> b) the date that is required for you to return to work or apply for reemployment after your military service has been completed.</p><p>[If the plan offers dependent coverage, add the following] Your dependents do not have an independent right to elect or waive continuation coverage.</p><p>Continuation coverage will cost: [Enter amount due each month or other permitted coverage period]. You do not have to send any payment with the Election Form. Important additional information about payment for continuation coverage is included in the pages following the Election Form.</p><p>If you have any questions about this notice or your rights to continuation coverage under USERRA, you should contact: [Enter name of plan administrator, with telephone number and address].</p><p>©2008 EAF Page 1 of 2 CONTINUATION COVERAGE ELECTION NOTICE UNDER USERRA</p><p>USERRA HEALTH CARE CONTINUATION COVERAGE ELECTION FORM (TO BE USED IN CONJUNCTION WITH COBRA NOTICE)</p><p>Instructions</p><p>To elect continuation coverage during a period of absence necessitated by service in the uniformed services, please complete this form and return it to: [Enter contact information].</p><p>You have [60 days] after the date of the notice in which to return it by mail [or describe any other means of submission]. If mailed, it must be post-marked no later than [Enter date].</p><p>If you do not submit a completed Election Form by the due date shown above, you will lose your right to elect continuation coverage. However, USERRA provides that coverage will be reinstated upon reemployment without an exclusion or waiting period.</p><p>Please check one box.</p><p> I elect continuation coverage pursuant to my USERRA rights in the [Enter name of plan].</p><p> I decline to elect continuation coverage pursuant to my USERRA rights in the [Enter name of plan].</p><p>Signature Date</p><p>Print Name</p><p>Print Address Telephone Number</p><p>©2008 EAF Page 2 of 2</p>