Common use of COBRA Clause in Contracts

COBRA. You may elect to continue group coverage under this plan if you would otherwise lose coverage because of a COBRA qualifying event. Please contact your Employer for detailed information about COBRA continuation coverage, including eligibility, election of coverage, and Premiums. If you enroll in COBRA and exhaust the time limit for COBRA group continuation coverage, you may be able to continue your group coverage under Cal-COBRA for a combined total (COBRA plus Cal-COBRA) of 36 months. You will not be eligible for benefits under Cal-COBRA if, at the time of the Cal-COBRA qualifying event, you are entitled to benefits under Medicare or are covered under another group health plan. Medicare entitlement means that you are eligible for Medicare benefits and enrolled in Part A only. A Cal-COBRA qualifying event is an event that, except for the election of continuation coverage, would result in a loss of coverage for the Subscriber or eligible Dependents: • The death of the Subscriber; • Termination of the Subscriber’s employment (except termination for gross misconduct which is not a qualifying event); • Reduction in hours of the Subscriber’s employment; • Divorce or legal separation of the Subscriber from the covered spouse; • Termination of the Subscriber’s domestic partnership with a covered Domestic Partner; • Loss of Dependent status by a covered Dependent; • The Subscriber’s entitlement to Medicare (This only applies to a covered Dependent); and • With respect to any of the above, such other qualifying event as may be added to Cal-COBRA. A child born to or placed for adoption with a covered Subscriber or Domestic Partner during the Cal-COBRA group coverage continuation period may be immediately added as a Dependent provided the Employer is properly notified of the birth or placement for adoption, and the child is enrolled within 31 days of the birth or placement for adoption. You are responsible for notifying Blue Shield in writing of the Subscriber’s death or Medicare entitlement, of divorce, legal separation, termination of a domestic partnership, or a Dependent’s loss of Dependent status under this plan. This notice must be given within 60 days of the date of the qualifying event. Failure to provide such notice within 60 days will disqualify you from receiving continuation coverage under Cal-COBRA. Your Employer is responsible for notifying Blue Shield in writing of the Subscriber’s termination or reduction of hours of employment within 30 days of the qualifying event. When Blue Shield is notified that a qualifying event has occurred, Blue Shield will, within 14 days, provide you with written notice of your right to continue group coverage under this plan. You must then give Blue Shield notice in writing of your election of continuation coverage within 60 days of the date of the notice of your right to continue group coverage, or the date coverage terminates due to the qualifying event, whichever is later. The written election notice must be delivered to Blue Shield by first-class mail or other reliable means. If you do not notify Blue Shield within 60 days, your coverage will terminate on the date you would have lost coverage because of the qualifying event. If this plan replaces a previous group plan that was in effect with your Employer, and you had elected Cal-COBRA continuation coverage under the previous plan, you may continue coverage under this plan for the balance of your Cal- COBRA eligibility period. To begin Cal-COBRA coverage with Blue Shield, you must notify us within 30 days of the date you were notified of the termination of your previous group plan. COBRA enrollees who reach the maximum coverage period available under COBRA may elect to continue coverage under Cal-COBRA for a combined maximum period of 36 months from the date continuation of coverage began under COBRA. You must notify Blue Shield of your Cal-COBRA election at least 30 days before COBRA termination. Your Cal-COBRA coverage will begin immediately after the COBRA coverage ends. You must exhaust all available COBRA coverage before you can become eligible to continue coverage under Cal-COBRA. Cal-COBRA enrollees will be eligible to continue Cal-COBRA coverage under this plan for up to a maximum of 36 months, regardless of the type of qualifying event. In no event will continuation of group coverage under COBRA, Cal-COBRA, or a combination of COBRA and Cal-COBRA be extended for more than 36 months from the date of the qualifying event that originally entitled you to continue your group coverage under this plan. Premiums for continuing coverage will be 110 percent of the applicable group Premium rate, except if you are eligible to continue Cal-COBRA coverage beyond 18 months because of a Social Security disability determination. In that case, the Premiums for months 19 through 36 will be 150 percent of the applicable group Premium rate. Cal-COBRA enrollees must submit Premiums directly to Blue Shield. The initial Premiums must be paid within 45 days of the date you provided written notification to Blue Shield of your election to continue coverage and must be sent to Blue Shield by first-class mail or other reliable means. You must pay the entire amount due within the 45-day period or you will be disqualified from Cal- COBRA continuation coverage. If your initial group continuation coverage is Cal-COBRA rather than COBRA, your Cal-COBRA coverage will begin on the date your coverage under this plan would otherwise end due to a qualifying event. Your coverage will continue for up to 36 months unless terminated due to an event described in the Termination of group continuation coverage section. The continuation of group coverage will cease if any one of the following events occurs prior to the expiration of the applicable period of continuation of group coverage: • Termination of the Contract (if your Employer continues to provide any group benefit plan for Employees, you may be able to continue coverage with another plan); • Failure to pay Premiums in full and on time to Blue Shield. Coverage will end as of the end of the period for which Premiums were paid; • You become covered under another group health plan; • You become entitled to Medicare; or • You commit fraud or deception in the use of the services of this Plan. Employers are responsible to ensure compliance with state and federal laws regarding leaves of absence, including the California Family Rights Act, the Family and Medical Leave Act, the Uniformed Services Employment and Re-employment Rights Act, and Labor Code requirements for Medical Disability.

COBRA. You may elect to continue group coverage under this plan if you would otherwise lose coverage because of a COBRA qualifying event. Please contact your Employer for detailed information about COBRA continuation coverage, including eligibility, election of coverage, and Premiums. If you enroll in COBRA and exhaust the time limit for COBRA group continuation coverage, you may be able to continue your group coverage under Cal-COBRA for a combined total (COBRA plus Cal-COBRA) of 36 months. You will not be eligible for benefits under Cal-COBRA if, at the time of the Cal-COBRA qualifying event, you are entitled to benefits under Medicare or are covered under another group health plan. Medicare entitlement means that you are eligible for Medicare benefits and enrolled in Part A only. A Cal-COBRA qualifying event is an event that, except for the election of continuation coverage, would result in a loss of coverage for the Subscriber or eligible Dependents: •  The death of the Subscriber; •  Termination of the Subscriber’s employment (except termination for gross misconduct which is not a qualifying event); •  Reduction in hours of the Subscriber’s employment; •  Divorce or legal separation of the Subscriber from the covered spouse; •  Termination of the Subscriber’s domestic partnership with a covered Domestic Partner; •  Loss of Dependent status by a covered Dependent; •  The Subscriber’s entitlement to Medicare (This only applies to a covered Dependent); and •  With respect to any of the above, such other qualifying event as may be added to Cal-COBRA. A child born to or placed for adoption with a covered Subscriber or Domestic Partner during the Cal-COBRA group coverage continuation period may be immediately added as a Dependent provided the Employer is properly notified of the birth or placement for adoption, and the child is enrolled within 31 days of the birth or placement for adoption. You are responsible for notifying Blue Shield in writing of the Subscriber’s death or Medicare entitlement, of divorce, legal separation, termination of a domestic partnership, or a Dependent’s loss of Dependent status under this plan. This notice must be given within 60 days of the date of the qualifying event. Failure to provide such notice within 60 days will disqualify you from receiving continuation coverage under Cal-COBRA. Your Employer is responsible for notifying Blue Shield in writing of the Subscriber’s termination or reduction of hours of employment within 30 days of the qualifying event. When Blue Shield is notified that a qualifying event has occurred, Blue Shield will, within 14 days, provide you with written notice of your right to continue group coverage under this plan. You must then give Blue Shield notice in writing of your election of continuation coverage within 60 days of the date of the notice of your right to continue group coverage, or the date coverage terminates due to the qualifying event, whichever is later. The written election notice must be delivered to Blue Shield by first-class mail or other reliable means. If you do not notify Blue Shield within 60 days, your coverage will terminate on the date you would have lost coverage because of the qualifying event. If this plan replaces a previous group plan that was in effect with your Employer, and you had elected Cal-COBRA continuation coverage under the previous plan, you may continue coverage under this plan for the balance of your Cal- COBRA eligibility period. To begin Cal-COBRA coverage with Blue Shield, you must notify us within 30 days of the date you were notified of the termination of your previous group plan. COBRA enrollees who reach the maximum coverage period available under COBRA may elect to continue coverage under Cal-COBRA for a combined maximum period of 36 months from the date continuation of coverage began under COBRA. You must notify Blue Shield of your Cal-COBRA election at least 30 days before COBRA termination. Your Cal-COBRA coverage will begin immediately after the COBRA coverage ends. You must exhaust all available COBRA coverage before you can become eligible to continue coverage under Cal-COBRA. Cal-COBRA enrollees will be eligible to continue Cal-COBRA coverage under this plan for up to a maximum of 36 months, regardless of the type of qualifying event. In no event will continuation of group coverage under COBRA, Cal-COBRA, or a combination of COBRA and Cal-COBRA be extended for more than 36 months from the date of the qualifying event that originally entitled you to continue your group coverage under this plan. Premiums for continuing coverage will be 110 percent of the applicable group Premium rate, except if you are eligible to continue Cal-COBRA coverage beyond 18 months because of a Social Security disability determination. In that case, the Premiums for months 19 through 36 will be 150 percent of the applicable group Premium rate. Cal-COBRA enrollees must submit Premiums directly to Blue Shield. The initial Premiums must be paid within 45 days of the date you provided written notification to Blue Shield of your election to continue coverage and must be sent to Blue Shield by first-class mail or other reliable means. You must pay the entire amount due within the 45-day period or you will be disqualified from Cal- COBRA continuation coverage. If your initial group continuation coverage is Cal-COBRA rather than COBRA, your Cal-COBRA coverage will begin on the date your coverage under this plan would otherwise end due to a qualifying event. Your coverage will continue for up to 36 months unless terminated due to an event described in the Termination of group continuation coverage section. The continuation of group coverage will cease if any one of the following events occurs prior to the expiration of the applicable period of continuation of group coverage: •  Termination of the Contract (if your Employer continues to provide any group benefit plan for Employees, you may be able to continue coverage with another plan); •  Failure to pay Premiums in full and on time to Blue Shield. Coverage will end as of the end of the period for which Premiums were paid; •  You become covered under another group health plan; •  You become entitled to Medicare; or •  You commit fraud or deception in the use of the services of this Plan. Employers are responsible to ensure compliance with state and federal laws regarding leaves of absence, including the California Family Rights Act, the Family and Medical Leave Act, the Uniformed Services Employment and Re-employment Rights Act, and Labor Code requirements for Medical Disability.

COBRA. You may elect If the Executive elects continuation coverage pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (“COBRA”), within the time period prescribed pursuant to COBRA for the Executive and the Executive’s eligible dependents, the Company will reimburse the Executive for the premiums necessary to continue group coverage health insurance benefits under this plan if you would otherwise lose coverage because of a COBRA qualifying event. Please contact your Employer for detailed information about COBRA continuation coverage, including eligibility, election of coverage, and Premiums. If you enroll in COBRA and exhaust the time limit for COBRA group continuation coverage, you may be able to continue your group coverage under Cal-COBRA for a combined total (COBRA plus Cal-COBRA) of 36 months. You will not be eligible for benefits under Cal-COBRA if, at the time of the Cal-COBRA qualifying event, you are entitled to benefits under Medicare or are covered under another group health plan. Medicare entitlement means that you are eligible for Medicare benefits and enrolled in Part A only. A Cal-COBRA qualifying event is an event that, except for the election of continuation coverage, would result in a loss of coverage for the Subscriber or eligible Dependents: • The death of the Subscriber; • Termination of the Subscriber’s employment (except termination for gross misconduct which is not a qualifying event); • Reduction in hours of the Subscriber’s employment; • Divorce or legal separation of the Subscriber from the covered spouse; • Termination of the Subscriber’s domestic partnership with a covered Domestic Partner; • Loss of Dependent status by a covered Dependent; • The Subscriber’s entitlement to Medicare (This only applies to a covered Dependent); and • With respect to any of the above, such other qualifying event as may be added to Cal-COBRA. A child born to or placed for adoption with a covered Subscriber or Domestic Partner during the Cal-COBRA group coverage continuation period may be immediately added as a Dependent provided the Employer is properly notified of the birth or placement for adoption, Executive and the child is enrolled within 31 days Executive’s eligible dependents until the earliest of (A) the birth or placement for adoption. You are responsible for notifying Blue Shield in writing of the Subscriber’s death or Medicare entitlement, of divorce, legal separation, termination of a domestic partnership, or a Dependent’s loss of Dependent status under this plan. This notice must be given within 60 days 12‑month anniversary of the date of the qualifying event. Failure Executive’s Qualified Termination, (B) the date upon which the Executive, and the Executive’s eligible dependents becomes covered under similar plans, or (C) the date upon which the Executive and the Executive’s eligible dependents, as applicable, ceases to provide such notice within 60 days will disqualify you from receiving continuation be eligible for coverage under Cal-COBRACOBRA (such reimbursements, the “COBRA Reimbursements”). Your Employer is responsible for notifying Blue Shield However, if the Company determines in writing its sole discretion that it cannot pay the COBRA Reimbursements without potentially violating applicable law (including, without limitation, Section 2716 of the Subscriber’s termination or reduction of hours of employment within 30 days of Public Health Service Act), the qualifying event. When Blue Shield is notified Company will in lieu thereof provide to the Executive a taxable lump-sum payment in an amount equal to the monthly COBRA premium that a qualifying event has occurred, Blue Shield will, within 14 days, provide you with written notice of your right the Executive would be required to pay to continue the Executive’s group health coverage under this plan. You must then give Blue Shield notice in writing of your election of continuation coverage within 60 days of effect on the date of the notice of your right to continue group coverage, or the date coverage terminates due to the qualifying event, whichever is later. The written election notice must Executive’s Qualified Termination (which amount will be delivered to Blue Shield by first-class mail or other reliable means. If you do not notify Blue Shield within 60 days, your coverage will terminate based on the date you would have lost coverage because premium for the first month of COBRA coverage), multiplied by twelve (12), which payments will be made regardless of whether the qualifying event. If this plan replaces a previous group plan that was in effect with your Employer, and you had elected Cal-Executive elects COBRA continuation coverage under and will commence on the previous planmonth following the Executive’s Qualified Termination. For the avoidance of doubt, you the taxable payment in lieu of COBRA Reimbursements may continue coverage under this plan be used for the balance of your Cal- COBRA eligibility period. To begin Cal-COBRA coverage with Blue Shieldany purpose, you must notify us within 30 days of the date you were notified of the termination of your previous group plan. COBRA enrollees who reach the maximum coverage period available under COBRA may elect including, but not limited to continue coverage under Cal-COBRA for a combined maximum period of 36 months from the date continuation of coverage began under COBRA. You must notify Blue Shield of your Cal-COBRA election at least 30 days before COBRA termination. Your Cal-COBRA coverage will begin immediately after the COBRA coverage ends. You must exhaust all available COBRA coverage before you can become eligible to continue coverage under Cal-COBRA. Cal-COBRA enrollees will be eligible to continue Cal-COBRA coverage under this plan for up to a maximum of 36 months, regardless of the type of qualifying event. In no event will continuation of group coverage under COBRA, Cal-COBRAand will be subject to all applicable tax withholdings. Notwithstanding anything to the contrary under this Agreement, or a combination of COBRA and Cal-COBRA be extended for more than 36 months from if at any time the date Company determines in its sole discretion that it cannot provide the payment contemplated by the preceding sentence without violating applicable law (including, without limitation, Section 2716 of the qualifying event that originally entitled you to continue your group coverage under this plan. Premiums for continuing coverage will be 110 percent of the applicable group Premium rate, except if you are eligible to continue Cal-COBRA coverage beyond 18 months because of a Social Security disability determination. In that casePublic Health Service Act), the Premiums Executive will not receive such payment or any further reimbursements for months 19 through 36 will be 150 percent of the applicable group Premium rate. Cal-COBRA enrollees must submit Premiums directly to Blue Shield. The initial Premiums must be paid within 45 days of the date you provided written notification to Blue Shield of your election to continue coverage and must be sent to Blue Shield by first-class mail or other reliable means. You must pay the entire amount due within the 45-day period or you will be disqualified from Cal- COBRA continuation coverage. If your initial group continuation coverage is Cal-COBRA rather than COBRA, your Cal-COBRA coverage will begin on the date your coverage under this plan would otherwise end due to a qualifying event. Your coverage will continue for up to 36 months unless terminated due to an event described in the Termination of group continuation coverage section. The continuation of group coverage will cease if any one of the following events occurs prior to the expiration of the applicable period of continuation of group coverage: • Termination of the Contract (if your Employer continues to provide any group benefit plan for Employees, you may be able to continue coverage with another plan); • Failure to pay Premiums in full and on time to Blue Shield. Coverage will end as of the end of the period for which Premiums were paid; • You become covered under another group health plan; • You become entitled to Medicare; or • You commit fraud or deception in the use of the services of this Plan. Employers are responsible to ensure compliance with state and federal laws regarding leaves of absence, including the California Family Rights Act, the Family and Medical Leave Act, the Uniformed Services Employment and Re-employment Rights Act, and Labor Code requirements for Medical DisabilityReimbursements.

COBRA. You may elect to continue group coverage under this plan if you would otherwise lose coverage because of a COBRA qualifying event. Please contact your Employer for detailed information about COBRA continuation coverage, including eligibility, election of coverage, and Premiums. If you enroll in COBRA and exhaust the time limit for COBRA group continuation coverage, you may be able to continue your group coverage under Cal-COBRA for a combined total (COBRA plus Cal-COBRA) of 36 months. You will not be eligible for benefits under Cal-COBRA if, at the time of the Cal-COBRA qualifying event, you are entitled to benefits under Medicare or are covered under another group health plan. Medicare entitlement means that you are eligible for Medicare benefits and enrolled in Part A only. A Cal-COBRA qualifying event is an event that, except for the election of continuation coverage, would result in a loss of coverage for the Subscriber or eligible Dependents: • The death of the Subscriber; • Termination of the Subscriber’s employment (except termination for gross misconduct which is not a qualifying event); • Reduction in hours of the Subscriber’s employment; • Divorce or legal separation of the Subscriber from the covered spouse; • Termination of the Subscriber’s domestic partnership with a covered Domestic Partner; • Loss of Dependent status by a covered Dependent; • The Subscriber’s entitlement to Medicare (This only applies to a covered Dependent); and • With respect to any of the above, such other qualifying event as may be added to Cal-COBRA. A child born to or placed for adoption with a covered Subscriber or Domestic Partner during the Cal-COBRA group coverage continuation period may be immediately added as a Dependent provided the Employer is properly notified of the birth or placement for adoption, and the child is enrolled within 31 30 days of after the birth or placement for adoption. You are responsible for notifying Blue Shield in writing of the Subscriber’s death or Medicare entitlement, of divorce, legal separation, termination of a domestic partnership, or a Dependent’s loss of Dependent status under this plan. This notice must be given within 60 days of the date of the qualifying event. Failure to provide such notice within 60 days will disqualify you from receiving continuation coverage under Cal-COBRA. Your Employer is responsible for notifying Blue Shield in writing of the Subscriber’s termination or reduction of hours of employment within 30 days of the qualifying event. When Blue Shield is notified that a qualifying event has occurred, Blue Shield will, within 14 days, provide you with written notice of your right to continue group coverage under this plan. You must then give Blue Shield notice in writing of your election of continuation coverage within 60 days of the date of the notice of your right to continue group coverage, or the date coverage terminates due to the qualifying event, whichever is later. The written election notice must be delivered to Blue Shield by first-class mail or other reliable means. If you do not notify Blue Shield within 60 days, your coverage will terminate on the date you would have lost coverage because of the qualifying event. If this plan replaces a previous group plan that was in effect with your Employer, and you had elected Cal-COBRA continuation coverage under the previous plan, you may continue coverage under this plan for the balance of your Cal- COBRA eligibility period. To begin Cal-COBRA coverage with Blue Shield, you must notify us within 30 days of the date you were notified of the termination of your previous group plan. COBRA enrollees who reach the maximum coverage period available under COBRA may elect to continue coverage under Cal-COBRA for a combined maximum period of 36 months from the date continuation of coverage began under COBRA. You must notify Blue Shield of your Cal-COBRA election at least 30 days before COBRA termination. Your Cal-COBRA coverage will begin immediately after the COBRA coverage ends. You must exhaust all available COBRA coverage before you can become eligible to continue coverage under Cal-COBRA. Cal-COBRA enrollees will be eligible to continue Cal-COBRA coverage under this plan for up to a maximum of 36 months, regardless of the type of qualifying event. In no event will continuation of group coverage under COBRA, Cal-COBRA, or a combination of COBRA and Cal-COBRA be extended for more than 36 months from the date of the qualifying event that originally entitled you to continue your group coverage under this plan. Premiums for continuing coverage will be 110 percent of the applicable group Premium rate, except if you are eligible to continue Cal-COBRA coverage beyond 18 months because of a Social Security disability determination. In that case, the Premiums for months 19 through 36 will be 150 percent of the applicable group Premium rate. Cal-COBRA enrollees must submit Premiums directly to Blue Shield. The initial Premiums must be paid within 45 days of the date you provided written notification to Blue Shield of your election to continue coverage and must be sent to Blue Shield by first-class mail or other reliable means. You must pay the entire amount due within the 45-day period or you will be disqualified from Cal- COBRA continuation coverage. If your initial group continuation coverage is Cal-COBRA rather than COBRA, your Cal-COBRA coverage will begin on the date your coverage under this plan would otherwise end due to a qualifying event. Your coverage will continue for up to 36 months unless terminated due to an event described in the Termination of group continuation coverage section. The continuation of group coverage will cease if any one of the following events occurs prior to the expiration of the applicable period of continuation of group coverage: • Termination of the Contract (if your Employer continues to provide any group benefit plan for Employees, you may be able to continue coverage with another plan); • Failure to pay Premiums in full and on time to Blue Shield. Coverage will end as of the end of the period for which Premiums were paid; • You become covered under another group health plan; • You become entitled to Medicare; or • You commit fraud or deception in the use of the services of this Plan. Employers are responsible to ensure compliance with state and federal laws regarding leaves of absence, including the California Family Rights Act, the Family and Medical Leave Act, the Uniformed Services Employment and Re-employment Rights Act, and Labor Code requirements for Medical Disability.

COBRA. You may elect If Executive elects continuation coverage pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (“COBRA”) for Executive and Executive’s eligible dependents within the time period prescribed pursuant to COBRA, the Company will reimburse Executive for the monthly premiums under COBRA necessary to continue group health insurance benefits for Executive and Executive’s eligible dependents (at the coverage levels in effect immediately prior to Executive’s termination) until the earlier of (A) the date upon which Executive and/or Executive’s eligible dependents becomes covered under this plan similar plans or (B) the last day of the Severance Period (such reimbursements, the “COBRA Premiums”). However, if you would otherwise lose coverage because the Company determines in its sole discretion that it cannot pay the COBRA Premiums without potentially violating applicable law (including, without limitation, Section 2716 of the Public Health Service Act), the Company will in lieu thereof provide to Executive a taxable monthly payment payable on the last day of a given month (except as provided by the following sentence), in an amount equal to the monthly COBRA qualifying event. Please contact your Employer for detailed information about COBRA continuation coverage, including eligibility, election of coverage, and Premiums. If you enroll in COBRA and exhaust the time limit for COBRA group continuation coverage, you may premium that Executive would be able required to pay to continue your group coverage under Cal-COBRA for a combined total (COBRA plus Cal-COBRA) of 36 months. You will not be eligible for benefits under Cal-COBRA if, at the time of the Cal-COBRA qualifying event, you are entitled to benefits under Medicare or are covered under another Executive’s group health plan. Medicare entitlement means that you are eligible for Medicare benefits and enrolled coverage in Part A only. A Cal-COBRA qualifying event is an event that, except for the election of continuation coverage, would result in a loss of coverage for the Subscriber or eligible Dependents: • The death of the Subscriber; • Termination of the Subscriber’s employment (except termination for gross misconduct which is not a qualifying event); • Reduction in hours of the Subscriber’s employment; • Divorce or legal separation of the Subscriber from the covered spouse; • Termination of the Subscriber’s domestic partnership with a covered Domestic Partner; • Loss of Dependent status by a covered Dependent; • The Subscriber’s entitlement to Medicare (This only applies to a covered Dependent); and • With respect to any of the above, such other qualifying event as may be added to Cal-COBRA. A child born to or placed for adoption with a covered Subscriber or Domestic Partner during the Cal-COBRA group coverage continuation period may be immediately added as a Dependent provided the Employer is properly notified of the birth or placement for adoption, and the child is enrolled within 31 days of the birth or placement for adoption. You are responsible for notifying Blue Shield in writing of the Subscriber’s death or Medicare entitlement, of divorce, legal separation, termination of a domestic partnership, or a Dependent’s loss of Dependent status under this plan. This notice must be given within 60 days of effect on the date of the qualifying event. Failure to provide such notice within 60 days will disqualify you from receiving continuation coverage under Cal-COBRA. Your Employer is responsible for notifying Blue Shield in writing of the SubscriberExecutive’s termination or reduction of hours of employment within 30 days of the qualifying event. When Blue Shield is notified that a qualifying event has occurred, Blue Shield will, within 14 days, provide you with written notice of your right to continue group coverage under this plan. You must then give Blue Shield notice in writing of your election of continuation coverage within 60 days of the date of the notice of your right to continue group coverage, or the date coverage terminates due to the qualifying event, whichever is later. The written election notice must (which amount will be delivered to Blue Shield by first-class mail or other reliable means. If you do not notify Blue Shield within 60 days, your coverage will terminate based on the date you would have lost coverage because premium for the first month of the qualifying event. If this plan replaces a previous group plan that was in effect with your EmployerCOBRA coverage), and you had elected Cal-which payments will be made regardless of whether Executive elects COBRA continuation coverage under and will commence on the previous plan, you may continue coverage under this plan for month following Executive’s termination of employment and will end on the balance earlier of your Cal- COBRA eligibility period. To begin Cal-COBRA coverage with Blue Shield, you must notify us within 30 days (x) the date upon which Executive obtains other employment or (y) the last day of the date you were notified Severance Period. For the avoidance of doubt, the termination taxable payments in lieu of your previous group plan. COBRA enrollees who reach the maximum coverage period available under COBRA Premiums may elect be used for any purpose, including, but not limited to continue coverage under Cal-COBRA for a combined maximum period of 36 months from the date continuation of coverage began under COBRA. You must notify Blue Shield of your Cal-COBRA election at least 30 days before COBRA termination. Your Cal-COBRA coverage will begin immediately after the COBRA coverage ends. You must exhaust all available COBRA coverage before you can become eligible to continue coverage under Cal-COBRA. Cal-COBRA enrollees will be eligible to continue Cal-COBRA coverage under this plan for up to a maximum of 36 months, regardless of the type of qualifying event. In no event will continuation of group coverage under COBRA, Cal-COBRAand will be subject to all applicable tax withholdings. Notwithstanding anything to the contrary under this Agreement, or a combination of COBRA and Cal-COBRA be extended for more than 36 months from if at any time the date Company determines in its sole discretion that it cannot provide the payments contemplated by the preceding sentence without violating applicable law (including, without limitation, Section 2716 of the qualifying event that originally entitled you to continue your group coverage under this planPublic Health Service Act), Executive will not receive such payment or any further reimbursements for COBRA premiums. Premiums for continuing coverage will be 110 percent of the applicable group Premium rate, except if you are eligible to continue Cal-COBRA coverage beyond 18 months because of a Social Security disability determination. In that case(Collectively, the Premiums for months 19 through 36 will be 150 percent of Company’s COBRA obligations in this paragraph are referred to as the applicable group Premium rate. Cal-“COBRA enrollees must submit Premiums directly to Blue Shield. The initial Premiums must be paid within 45 days of the date you provided written notification to Blue Shield of your election to continue coverage and must be sent to Blue Shield by first-class mail or other reliable means. You must pay the entire amount due within the 45-day period or you will be disqualified from Cal- COBRA continuation coverage. If your initial group continuation coverage is Cal-COBRA rather than COBRA, your Cal-COBRA coverage will begin on the date your coverage under this plan would otherwise end due to a qualifying event. Your coverage will continue for up to 36 months unless terminated due to an event described in the Termination of group continuation coverage section. The continuation of group coverage will cease if any one of the following events occurs prior to the expiration of the applicable period of continuation of group coverage: • Termination of the Contract (if your Employer continues to provide any group benefit plan for Employees, you may be able to continue coverage with another planPayments”); • Failure to pay Premiums in full and on time to Blue Shield. Coverage will end as of the end of the period for which Premiums were paid; • You become covered under another group health plan; • You become entitled to Medicare; or • You commit fraud or deception in the use of the services of this Plan. Employers are responsible to ensure compliance with state and federal laws regarding leaves of absence, including the California Family Rights Act, the Family and Medical Leave Act, the Uniformed Services Employment and Re-employment Rights Act, and Labor Code requirements for Medical Disability.

COBRA. You may elect The following rules apply only to continue group Groups with twenty (20) or more employees on 50% of the workdays in the previous Calendar Year. For the purposes of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) and the Omnibus Budget Reconciliation Act of 1989 (OBRA), Group shall be considered the Plan Administrator. a) A Subscriber and any enrolled Dependent who would lose coverage under this plan if you would otherwise lose coverage Plan because of: 1) a reduction in the Subscriber’s regularly scheduled work hours, or 2) because of a COBRA qualifying event. Please contact your Employer for detailed information about COBRA continuation coverage, including eligibility, election of coverage, and Premiums. If you enroll in COBRA and exhaust the time limit for COBRA group continuation coverage, you may be able to continue your group coverage under Cal-COBRA for a combined total (COBRA plus Cal-COBRA) of 36 months. You will not be eligible for benefits under Cal-COBRA if, at the time of the Cal-COBRA qualifying event, you are entitled to benefits under Medicare or are covered under another group health plan. Medicare entitlement means that you are eligible for Medicare benefits and enrolled in Part A only. A Cal-COBRA qualifying event is an event that, except for the election of continuation coverage, would result in a loss of coverage for the Subscriber or eligible Dependents: • The death of the Subscriber; • Termination termination of the Subscriber’s employment with the Group for any reason, other than gross misconduct, has the right to elect COBRA continuation coverage. Such coverage may continue for up to eighteen (except 18) months. The premium for this COBRA continuation coverage may be increased to 102% of the premium for providing coverage to other Subscribers under this Plan. COBRA continuation coverage will not take effect until the Subscriber or Dependent elects COBRA and makes the required payment. The Subscriber or Dependent will have an initial grace period of forty -five (45) days fromthe date of COBRA election to make the first premiumpayment. If the qualifying event is: 1) a reduction in the Subscriber’s regularly scheduled work hours, or 2) because of termination for gross misconduct which is not a qualifying event); • Reduction in hours of the Subscriber’s employment; • Divorce or legal separation of employment with the Group for any reason other than gross misconduct and the Subscriber from the covered spouse; • Termination of the Subscriber’s domestic partnership with a covered Domestic Partner; • Loss of Dependent status by a covered Dependent; • The Subscriber’s entitlement became entitled to Medicare benefits less than eighteen (This only applies 18) months before the qualifying event, then COBRA continuation coverage for Dependents may continue for up to a covered Dependent); and • With respect thirty-six(36) months after the initially determined date of Medicare entitlement. b) A Dependent who would lose coverage under this Plan due to any of the above, such other qualifying event as may be added to Cal-COBRA. A child born to or placed for adoption with a covered Subscriber or Domestic Partner during events shown below has the Cal-COBRA group coverage continuation period may be immediately added as a Dependent provided the Employer is properly notified of the birth or placement for adoption, and the child is enrolled within 31 days of the birth or placement for adoption. You are responsible for notifying Blue Shield in writing of the Subscriber’s death or Medicare entitlement, of divorce, legal separation, termination of a domestic partnership, or a Dependent’s loss of Dependent status under this plan. This notice must be given within 60 days of the date of the qualifying event. Failure to provide such notice within 60 days will disqualify you from receiving continuation coverage under Cal-COBRA. Your Employer is responsible for notifying Blue Shield in writing of the Subscriber’s termination or reduction of hours of employment within 30 days of the qualifying event. When Blue Shield is notified that a qualifying event has occurred, Blue Shield will, within 14 days, provide you with written notice of your right to continue group coverage under this plan. You must then give Blue Shield notice in writing of your election of continuation coverage within 60 days of the date of the notice of your right to continue group coverage, or the date coverage terminates due to the qualifying event, whichever is later. The written election notice must be delivered to Blue Shield by first-class mail or other reliable means. If you do not notify Blue Shield within 60 days, your coverage will terminate on the date you would have lost coverage because of the qualifying event. If this plan replaces a previous group plan that was in effect with your Employer, and you had elected Cal-COBRA continuation coverage under the previous plan, you may continue coverage under this plan for the balance of your Cal- COBRA eligibility period. To begin Cal-COBRA coverage with Blue Shield, you must notify us within 30 days of the date you were notified of the termination of your previous group plan. COBRA enrollees who reach the maximum coverage period available under COBRA may elect to continue coverage under Cal-COBRA for a combined maximum period of 36 months from the date continuation of coverage began under COBRA. You must notify Blue Shield of your Cal-COBRA election at least 30 days before COBRA termination. Your Cal-COBRA coverage will begin immediately after the COBRA coverage ends. You must exhaust all available COBRA coverage before you can become eligible to continue coverage under Cal-COBRA. Cal-COBRA enrollees will be eligible to continue Cal-COBRA coverage under this plan for up to a maximum of 36 months, regardless of the type of qualifying event. In no event will continuation of group coverage under COBRA, Cal-COBRA, or a combination of COBRA and Cal-COBRA be extended for more than 36 months from the date of the qualifying event that originally entitled you to continue your group coverage under this plan. Premiums for continuing coverage will be 110 percent of the applicable group Premium rate, except if you are eligible to continue Cal-COBRA coverage beyond 18 months because of a Social Security disability determination. In that case, the Premiums for months 19 through 36 will be 150 percent of the applicable group Premium rate. Cal-COBRA enrollees must submit Premiums directly to Blue Shield. The initial Premiums must be paid within 45 days of the date you provided written notification to Blue Shield of your election to continue coverage and must be sent to Blue Shield by first-class mail or other reliable means. You must pay the entire amount due within the 45-day period or you will be disqualified from Cal- COBRA continuation coverage. If your initial group continuation Such coverage is Cal-COBRA rather than COBRA, your Cal-COBRA coverage will begin on the date your coverage under this plan would otherwise end due to a qualifying event. Your coverage will may continue for up to 36 months unless terminated due thirty-six(36) months. 1. The Subscriber’s death. 2. The Subscriber’s divorce or legal separation. 3. The Subscriber becomes entitled to an event described Medicare benefits under Part A, Part B, or both. 4. A Dependent no longer qualifies as a Dependent child as provided in the Termination Section 1. of group this Certificate. The premium for continuation coverage section. The continuation of group coverage will cease if any one may be increased to 102% of the following events occurs prior premium for providing coverage to the expiration of the applicable period of continuation of group coverage: • Termination of the Contract (if your Employer continues to provide any group benefit plan for Employees, you may be able to continue coverage with another plan); • Failure to pay Premiums in full and on time to Blue Shield. Coverage will end as of the end of the period for which Premiums were paid; • You become covered other individuals under another group health plan; • You become entitled to Medicare; or • You commit fraud or deception in the use of the services of this Plan. Employers are responsible to ensure compliance with state and federal laws regarding leaves of absence, including the California Family Rights Act, the Family and Medical Leave Act, the Uniformed Services Employment and Re-employment Rights Act, and Labor Code requirements for Medical Disability.

COBRA. You may elect The following rules apply only to continue group Groups with twenty (20) or more employees on 50% of the workdays in the previous Calendar Year. For the purposes of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) and the Omnibus Budget Reconciliation Act of 1989 (OBRA), Group shall be considered the Plan Administrator. a) A Subscriber and any enrolled Dependent who would lose coverage under this plan if you would otherwise lose coverage Plan because of: 1) a reduction in the Subscriber’s regularly scheduled work hours, or 2) because of a COBRA qualifying event. Please contact your Employer for detailed information about COBRA continuation coverage, including eligibility, election of coverage, and Premiums. If you enroll in COBRA and exhaust the time limit for COBRA group continuation coverage, you may be able to continue your group coverage under Cal-COBRA for a combined total (COBRA plus Cal-COBRA) of 36 months. You will not be eligible for benefits under Cal-COBRA if, at the time of the Cal-COBRA qualifying event, you are entitled to benefits under Medicare or are covered under another group health plan. Medicare entitlement means that you are eligible for Medicare benefits and enrolled in Part A only. A Cal-COBRA qualifying event is an event that, except for the election of continuation coverage, would result in a loss of coverage for the Subscriber or eligible Dependents: • The death of the Subscriber; • Termination termination of the Subscriber’s employment with the Group for any reason, other than gross misconduct, has the right to elect COBRA continuation coverage. Such coverage may continue for up to eighteen (except 18) months. The premium for this COBRA continuation coverage may be increased to 102% of the premium for providing coverage to other Subscribers under this Plan. COBRA continuation coverage will not take effect until the Subscriber or Dependent elects COBRA and makes the required payment. The Subscriber or Dependent will have an initial grace period of forty-five (45) days from the date of COBRA election to make the first premium payment. If the qualifying event is: 1) a reduction in the Subscriber’s regularly scheduled work hours, or 2) because of termination for gross misconduct which is not a qualifying event); • Reduction in hours of the Subscriber’s employment; • Divorce or legal separation of employment with the Group for any reason other than gross misconduct and the Subscriber from the covered spouse; • Termination of the Subscriber’s domestic partnership with a covered Domestic Partner; • Loss of Dependent status by a covered Dependent; • The Subscriber’s entitlement became entitled to Medicare benefits less than eighteen (This only applies 18) months before the qualifying event, then COBRA continuation coverage for Dependents may continue for up to a covered Dependent); and • With respect thirty-six (36) months after the initially determined date of Medicare entitlement. b) A Dependent who would lose coverage under this Plan due to any of the above, such other qualifying event as may be added to Cal-COBRA. A child born to or placed for adoption with a covered Subscriber or Domestic Partner during events shown below has the Cal-COBRA group coverage continuation period may be immediately added as a Dependent provided the Employer is properly notified of the birth or placement for adoption, and the child is enrolled within 31 days of the birth or placement for adoption. You are responsible for notifying Blue Shield in writing of the Subscriber’s death or Medicare entitlement, of divorce, legal separation, termination of a domestic partnership, or a Dependent’s loss of Dependent status under this plan. This notice must be given within 60 days of the date of the qualifying event. Failure to provide such notice within 60 days will disqualify you from receiving continuation coverage under Cal-COBRA. Your Employer is responsible for notifying Blue Shield in writing of the Subscriber’s termination or reduction of hours of employment within 30 days of the qualifying event. When Blue Shield is notified that a qualifying event has occurred, Blue Shield will, within 14 days, provide you with written notice of your right to continue group coverage under this plan. You must then give Blue Shield notice in writing of your election of continuation coverage within 60 days of the date of the notice of your right to continue group coverage, or the date coverage terminates due to the qualifying event, whichever is later. The written election notice must be delivered to Blue Shield by first-class mail or other reliable means. If you do not notify Blue Shield within 60 days, your coverage will terminate on the date you would have lost coverage because of the qualifying event. If this plan replaces a previous group plan that was in effect with your Employer, and you had elected Cal-COBRA continuation coverage under the previous plan, you may continue coverage under this plan for the balance of your Cal- COBRA eligibility period. To begin Cal-COBRA coverage with Blue Shield, you must notify us within 30 days of the date you were notified of the termination of your previous group plan. COBRA enrollees who reach the maximum coverage period available under COBRA may elect to continue coverage under Cal-COBRA for a combined maximum period of 36 months from the date continuation of coverage began under COBRA. You must notify Blue Shield of your Cal-COBRA election at least 30 days before COBRA termination. Your Cal-COBRA coverage will begin immediately after the COBRA coverage ends. You must exhaust all available COBRA coverage before you can become eligible to continue coverage under Cal-COBRA. Cal-COBRA enrollees will be eligible to continue Cal-COBRA coverage under this plan for up to a maximum of 36 months, regardless of the type of qualifying event. In no event will continuation of group coverage under COBRA, Cal-COBRA, or a combination of COBRA and Cal-COBRA be extended for more than 36 months from the date of the qualifying event that originally entitled you to continue your group coverage under this plan. Premiums for continuing coverage will be 110 percent of the applicable group Premium rate, except if you are eligible to continue Cal-COBRA coverage beyond 18 months because of a Social Security disability determination. In that case, the Premiums for months 19 through 36 will be 150 percent of the applicable group Premium rate. Cal-COBRA enrollees must submit Premiums directly to Blue Shield. The initial Premiums must be paid within 45 days of the date you provided written notification to Blue Shield of your election to continue coverage and must be sent to Blue Shield by first-class mail or other reliable means. You must pay the entire amount due within the 45-day period or you will be disqualified from Cal- COBRA continuation coverage. If your initial group continuation Such coverage is Cal-COBRA rather than COBRA, your Cal-COBRA coverage will begin on the date your coverage under this plan would otherwise end due to a qualifying event. Your coverage will may continue for up to 36 months unless terminated due thirty-six (36) months. 1. The Subscriber’s death. 2. The Subscriber’s divorce or legal separation. 3. The Subscriber becomes entitled to an event described Medicare benefits under Part A, Part B, or both. 4. A Dependent no longer qualifies as a Dependent child as provided in the Termination Section 1. of group this Certificate. The premium for continuation coverage section. The continuation of group coverage will cease if any one may be increased to 102% of the following events occurs prior premium for providing coverage to the expiration of the applicable period of continuation of group coverage: • Termination of the Contract (if your Employer continues to provide any group benefit plan for Employees, you may be able to continue coverage with another plan); • Failure to pay Premiums in full and on time to Blue Shield. Coverage will end as of the end of the period for which Premiums were paid; • You become covered other individuals under another group health plan; • You become entitled to Medicare; or • You commit fraud or deception in the use of the services of this Plan. Employers are responsible to ensure compliance with state and federal laws regarding leaves of absence, including the California Family Rights Act, the Family and Medical Leave Act, the Uniformed Services Employment and Re-employment Rights Act, and Labor Code requirements for Medical Disability.

COBRA. You may elect to continue group coverage under this plan if you would otherwise lose coverage because of a COBRA qualifying event. Please contact your Employer for detailed information about COBRA continuation coverage, including eligibility, election of coverage, and Premiums. If you enroll in COBRA and exhaust the time limit for COBRA group continuation coverage, you may be able to continue your group coverage under Cal-COBRA for a combined total (COBRA plus Cal-COBRA) of 36 months. You will not be eligible for benefits under Cal-COBRA if, at the time of the Cal-COBRA qualifying event, you are entitled to benefits under Medicare or are covered under another group health plan. Medicare entitlement means that you are eligible for Medicare benefits and enrolled in Part A only. A Cal-COBRA qualifying event is an event that, except for the election of continuation coverage, would result in a loss of coverage for the Subscriber or eligible Dependents: • The death of the Subscriber; • Termination of the Subscriber’s employment (except termination for gross misconduct which is not a qualifying event); • Reduction in hours of the Subscriber’s employment; • Divorce or legal separation of the Subscriber from the covered spouse; • Termination of the Subscriber’s domestic partnership with a covered Domestic Partner; • Loss of Dependent status by a covered Dependent; • The Subscriber’s entitlement to Medicare (This only applies to a covered Dependent); and • With respect to any of the above, such other qualifying event as may be added to Cal-COBRA. A child born to or placed for adoption with a covered Subscriber or Domestic Partner during the Cal-COBRA group coverage continuation period may be immediately added as a Dependent provided the Employer is properly notified of the birth or placement for adoption, and the child is enrolled within 31 60 days of the birth or placement for adoption. You are responsible for notifying Blue Shield in writing of the Subscriber’s death or Medicare entitlement, of divorce, legal separation, termination of a domestic partnership, or a Dependent’s loss of Dependent status under this plan. This notice must be given within 60 days of the date of the qualifying event. Failure to provide such notice within 60 days will disqualify you from receiving continuation coverage under Cal-COBRA. Your Employer is responsible for notifying Blue Shield in writing of the Subscriber’s termination or reduction of hours of employment within 30 days of the qualifying event. When Blue Shield is notified that a qualifying event has occurred, Blue Shield will, within 14 days, provide you with written notice of your right to continue group coverage under this plan. You must then give Blue Shield notice in writing of your election of continuation coverage within 60 days of the date of the notice of your right to continue group coverage, or the date coverage terminates due to the qualifying event, whichever is later. The written election notice must be delivered to Blue Shield by first-class mail or other reliable means. If you do not notify Blue Shield within 60 days, your coverage will terminate on the date you would have lost coverage because of the qualifying event. If this plan replaces a previous group plan that was in effect with your Employer, and you had elected Cal-COBRA continuation coverage under the previous plan, you may continue coverage under this plan for the balance of your Cal- COBRA eligibility period. To begin Cal-COBRA coverage with Blue Shield, you must notify us within 30 days of the date you were notified of the termination of your previous group plan. COBRA enrollees who reach the maximum coverage period available under COBRA may elect to continue coverage under Cal-COBRA for a combined maximum period of 36 months from the date continuation of coverage began under COBRA. You must notify Blue Shield of your Cal-COBRA election at least 30 days before COBRA termination. Your Cal-COBRA coverage will begin immediately after the COBRA coverage ends. You must exhaust all available COBRA coverage before you can become eligible to continue coverage under Cal-COBRA. Cal-COBRA enrollees will be eligible to continue Cal-COBRA coverage under this plan for up to a maximum of 36 months, regardless of the type of qualifying event. In no event will continuation of group coverage under COBRA, Cal-COBRA, or a combination of COBRA and Cal-COBRA be extended for more than 36 months from the date of the qualifying event that originally entitled you to continue your group coverage under this plan. Premiums for continuing coverage will be 110 percent of the applicable group Premium rate, except if you are eligible to continue Cal-COBRA coverage beyond 18 months because of a Social Security disability determination. In that case, the Premiums for months 19 through 36 will be 150 percent of the applicable group Premium rate. Cal-COBRA enrollees must submit Premiums directly to Blue Shield. The initial Premiums must be paid within 45 days of the date you provided written notification to Blue Shield of your election to continue coverage and must be sent to Blue Shield by first-class mail or other reliable means. You must pay the entire amount due within the 45-day period or you will be disqualified from Cal- COBRA continuation coverage. If your initial group continuation coverage is Cal-COBRA rather than COBRA, your Cal-COBRA coverage will begin on the date your coverage under this plan would otherwise end due to a qualifying event. Your coverage will continue for up to 36 months unless terminated due to an event described in the Termination of group continuation coverage section. The continuation of group coverage will cease if any one of the following events occurs prior to the expiration of the applicable period of continuation of group coverage: • Termination of the Contract (if your Employer continues to provide any group benefit plan for Employees, you may be able to continue coverage with another plan); • Failure to pay Premiums in full and on time to Blue Shield. Coverage will end as of the end of the period for which Premiums were paid; • You become covered under another group health plan; • You become entitled to Medicare; or • You commit fraud or deception in the use of the services of this Plan. Employers are responsible to ensure compliance with state and federal laws regarding leaves of absence, including the California Family Rights Act, the Family and Medical Leave Act, the Uniformed Services Employment and Re-employment Rights Act, and Labor Code requirements for Medical Disability.

COBRA. You may elect The Consolidated Omnibus Budget Reconciliation Act (COBRA) permits you and any covered dependents to continue group medical and dental coverage under this plan if for up to 18 months from your qualifying event date. The COBRA coverage rate is 102 percent of the full cost of coverage. The COBRA period may be extended in certain cases of disability or in the event you would otherwise lose coverage because of or a COBRA covered dependent have a second qualifying event. Please contact Although you are eligible to continue medical and dental coverage at no cost during the six months following your Employer for detailed information about effective date of retirement, the coverage is still considered to be part of the COBRA continuation coverage, including eligibility, election of coverageperiod, and Premiumsyou must complete a COBRA election form if you wish to have this six months of no cost coverage. If you enroll in COBRA and exhaust wish medical and/or dental coverage to continue beyond the time limit for COBRA group continuation six months of no cost coverage, you may be able will receive another COBRA election form with the applicable rates noted for you to continue your group elect continued coverage under Cal-COBRA for a combined total (COBRA plus Cal-COBRA) of 36 months. You will not be eligible for benefits under Cal-COBRA if, at the time of the Cal-COBRA qualifying event, you are entitled to benefits under Medicare or are covered under another group health plan. Medicare entitlement means that you are eligible for Medicare benefits and enrolled in Part A only. A Cal-COBRA qualifying event is an event that, except for the election of continuation coverage, would result in a loss of coverage for the Subscriber or eligible Dependents: • The death of the Subscriber; • Termination of the Subscriber’s employment (except termination for gross misconduct which is not a qualifying event); • Reduction in hours of the Subscriber’s employment; • Divorce or legal separation of the Subscriber from the covered spouse; • Termination of the Subscriber’s domestic partnership with a covered Domestic Partner; • Loss of Dependent status by a covered Dependent; • The Subscriber’s entitlement to Medicare (This only applies to a covered Dependent); and • With respect to any of the above, such other qualifying event as may be added to Cal-COBRA. A child born to or placed Your election for adoption with a covered Subscriber or Domestic Partner during the Cal-COBRA group coverage continuation period may be immediately added as a Dependent provided the Employer is properly notified of the birth or placement for adoption, and the child is enrolled within 31 days of the birth or placement for adoption. You are responsible for notifying Blue Shield in writing of the Subscriber’s death or Medicare entitlement, of divorce, legal separation, termination of a domestic partnership, or a Dependent’s loss of Dependent status under this plan. This notice must be given made within 60 days of the date of the qualifying event. Failure to provide such notice within 60 days will disqualify you from receiving continuation coverage under Cal-COBRA. Your Employer is responsible for notifying Blue Shield in writing of the Subscriber’s termination or reduction of hours of employment within 30 days of the qualifying event. When Blue Shield is are notified that a qualifying event has occurred, Blue Shield will, within 14 days, provide you with written notice of your right to continue group coverage under this plan. You must then give Blue Shield notice in writing of your election of continuation coverage within 60 days of COBRA eligibility or the date of the notice of your right to continue group coverage, or the date coverage terminates due to the qualifying event, whichever is later. The written Additional information and necessary forms for enrolling in COBRA will be forwarded to you under separate cover, including the qualifying event date, the COBRA election notice must be delivered to Blue Shield by first-class mail or other reliable meansperiod and a list of events which terminate COBRA coverage. If you do not notify Blue Shield within 60 days, your • Basic Life/AD&D Insurance – Basic life/AD&D coverage will terminate cease on the your effective date you would have lost of retirement. You can convert your basic life coverage because of the qualifying event. If this plan replaces (excluding AD&D) to a previous group plan that was in effect with your Employer, and you had elected Cal-COBRA continuation coverage under the previous plan, you may continue coverage under this plan for the balance of your Cal- COBRA eligibility period. To begin Cal-COBRA coverage with Blue Shield, you must notify us personal policy within 30 31 days of the date you were notified of the termination of your previous group plan. COBRA enrollees who reach the maximum coverage period available under COBRA may elect to continue coverage under Cal-COBRA for a combined maximum period of 36 months from the date continuation cessation of coverage began under COBRAwithout taking a medical examination or showing evidence of good health. You must notify Blue Shield of Contact your Callocal METLIFE office for further information. To locate an office in your area, call 0-COBRA election at least 30 days before COBRA termination000-XXX-XXXX. Your Cal-COBRA coverage will begin immediately after the COBRA coverage ends. You must exhaust all available COBRA coverage before you • Optional GUL Life/AD&D, Optional GUL Dependent Spouse’s Life/AD&D and Optional GUL Dependent Child Life Insurance - These optional GUL coverages can become eligible to continue coverage under Cal-COBRA. Cal-COBRA enrollees will be eligible to continue Cal-COBRA coverage under this plan for up to a maximum of 36 months, regardless of the type of qualifying event. In no event will continuation of group coverage under COBRA, Cal-COBRA, or a combination of COBRA and Cal-COBRA be extended for more than 36 months from the continued following your effective date of retirement under the qualifying event that originally entitled GUL portability provisions with METLIFE. METLIFE will contact you to continue your group coverage under this plan. Premiums for continuing coverage will be 110 percent of the applicable group Premium rate, except if you are eligible to continue Cal-COBRA coverage beyond 18 months because of a Social Security disability determination. In that case, the Premiums for months 19 through 36 will be 150 percent of the applicable group Premium rate. Cal-COBRA enrollees must submit Premiums directly to Blue Shield. The initial Premiums must be paid within 45 days of the date you provided written notification to Blue Shield of your election to continue coverage and must be sent to Blue Shield by first-class mail or other reliable means. You must pay the entire amount due within the 45-day period or you will be disqualified from Cal- COBRA continuation coverage. If your initial group continuation coverage is Cal-COBRA rather than COBRA, your Cal-COBRA coverage will begin on the date your coverage under this plan would otherwise end due to a qualifying eventprocess for making contributions. • Travel Accident Insurance - Your coverage will continue for up to 36 months unless terminated due to an event described in the Termination of group continuation coverage section. The continuation of group travel accident coverage will cease if any one on your effective date of the following events occurs prior to the expiration of the applicable period of continuation of group retirement. There is no conversion option available for this coverage: • Termination of the Contract (if your Employer continues to provide any group benefit plan for Employees, you may be able to continue coverage with another plan); • Failure to pay Premiums in full and on time to Blue Shield. Coverage will end as of the end of the period for which Premiums were paid; • You become covered under another group health plan; • You become entitled to Medicare; or • You commit fraud or deception in the use of the services of this Plan. Employers are responsible to ensure compliance with state and federal laws regarding leaves of absence, including the California Family Rights Act, the Family and Medical Leave Act, the Uniformed Services Employment and Re-employment Rights Act, and Labor Code requirements for Medical Disability.