Common use of COBRA Information Clause in Contracts

COBRA Information. Are you subject to COBRA? Yes No NOTE: You are subject to COBRA if you or your controlled group, as defined in 26 U.S.C. 1563, employed at least 20 full or part-time employees on at least 50% of the typical business days during the previous calendar year. You must include employees residing outside the U.S. Will Acuity Group administer COBRA coverage? Yes No If no, please provide administrator information: Name: Address: Phone: Fax: Is anyone in your group currently under COBRA, state continuation plan, or within their election period? Yes No If yes, please list below: NOTE: Any COBRA applications received after approval of this application may result in a rate adjustment or declination. Employee/Dependent Termination Date of Original Coverage Qualifying Event

COBRA Information. Are you subject to COBRA? Yes No NOTE: You are subject to COBRA if you or your controlled group, as defined in 26 U.S.C. 1563, employed at least 20 full or part-time employees on at least 50% of the typical business days during the previous calendar year. You must include employees residing outside the U.S. Will Acuity Group Xxxx Xxxxxx administer COBRA coverage? Yes No If no, please provide administrator information: Name: Address: Phone: Fax: Is anyone in your group currently under COBRA, state continuation plan, or within their election period? Yes No If yes, please list below: NOTE: Any COBRA applications received after approval of this application may result in a rate adjustment or declination. Employee/Dependent Termination Date of Original Coverage Qualifying Event

COBRA Information. Are you subject to COBRA? Yes No NOTE: You are subject to COBRA if you or your controlled group, as defined in 26 U.S.C. 1563, employed at least 20 full or part-time employees on at least 50% of the typical business days during the previous calendar year. You must include employees residing outside the U.S. Will Acuity Group Resources administer COBRA coverage? Yes No If no, please provide administrator information: Name: Address: Phone: Fax: Is anyone in your group currently under COBRA, state continuation plan, or within their election period? Yes No If yes, please list below: NOTE: Any COBRA applications received after approval of this application may result in a rate adjustment or declination. Employee/Dependent Termination Date of Original Coverage Qualifying Event

COBRA Information. Are you subject to COBRA? Yes No NOTE: You are subject to COBRA if you or your controlled group, as defined in 26 U.S.C. 1563, employed at least 20 full or part-time employees on at least 50% of the typical business days during the previous calendar year. You must include employees residing outside the U.S. Will Acuity Group administer Meritain Administer COBRA coverage? Yes No If no, please provide administrator information: Name: Address: Phone: Fax: Is anyone in your group currently under COBRA, state continuation plan, or within their election period? Yes No If yes, please list below: NOTE: Any COBRA applications received after approval of this application may result in a rate adjustment or declination. Employee/Dependent Termination Date of Original Coverage Qualifying Event