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 Meritain Administer COBRA coverage? Yes No If no, please provide administrator information: Name: Address: Phone: Fax:
COBRA Information. Seller agrees to use its best efforts to provide expeditiously to Purchaser or its Representatives all information that such Person deems necessary to determine whether there has been any failure to comply with the continuation health care requirements of Section 4980B of the Code and Part 6 of Title I of ERISA as such requirements have applied to any group health plan maintained by or for Seller which failure occurred with respect to any current or former employee of Seller or any spouse, former spouse, dependent child, or former dependent child of any such employee, on or prior to the Closing Date. Seller further agrees to use its best efforts to provide expeditiously to Purchaser or its Representatives all information that such Person deems necessary to correct any failures to comply with such continuation health care coverage requirements. Such information will include the identification of all covered employees (as defined in Section 4980(B)(f)(7) of the Code) and their qualified beneficiaries (as defined in Section 4980B(g)(1) of the Code), the identification of all qualifying events with respect to such covered employees or qualified beneficiaries (as defined in Section 4980B(f)(3) of the Code) and information otherwise demonstrating compliance with all of the continuation health coverage requirements of Section 4980B of the Code and Part 6 of Title I of ERISA.
COBRA Information. Within five days after the Closing Date, Buyer shall supplement the Disclosure Letter with an additional Part 3.16(k), which shall contain a true and correct list of the persons who are then covered under a Seller's group health plan pursuant to the application of COBRA (including persons who were enrolled in a Seller's group health plan by a COBRA qualified beneficiary after the occurrence of a COBRA qualifying event), and, with respect to each such person, (1) the nature of the COBRA qualifying event that entitled such person to COBRA continuation coverage (or the other reason the person is covered under a Seller's group health plan), (2) the date on which such person's COBRA qualifying event occurred, (3) the date on which such person's COBRA continuation coverage will expire (based upon current facts), and (4) the address of such person. Part 3.16(k) shall contain a true and correct list of the persons who are then eligible to elect continuation coverage under a Seller's group health plan pursuant to the application of COBRA but have not yet done so, and, with respect to each such person, (1) the nature of the COBRA qualifying event that entitles such person to COBRA continuation coverage, (2) the date on which such person's COBRA qualifying event occurred, (3) the most recent date on which such person was given a notification of his right to elect COBRA continuation coverage with respect to a Seller's group health plan, (4) the date on which such person's COBRA continuation coverage, if elected, would expire (based upon current facts), and (5) the address of such person. Part 3.16(k) shall also contain a true and correct list of every then current employee of a Seller who is participating in a Seller's group health plan and, with respect to each such employee, (1) the address of such employee, (2) the name and address of such employee's spouse if the spouse is covered under the Seller's group health plan, and (3) the name and address of each such employee's dependent children who are covered under the Seller's group health plan. All technical terms used in this Section 3.16(k) shall have the meanings ascribed to them in COBRA.
