• HOUSE STAFF BENEFITS PLAN

    HOUSE STAFF BENEFITS PLAN

    LA General, LAC-Harbor-UCLA, MLK Hospital & Rancho Los Amigos Center

  • COBRA CONTINUATION COVERAGE ELECTION FORM

    Instructions: To elect COBRA continuation coverage, complete this Election Form and return it to us. Under federal law, you have 60 days after the later of the date of this notice or the date on which you lose (or would lose) coverage under the Plan (the "Due Date") to decide whether you want to elect COBRA continuation coverage under the Plan, unless you are entitled to additional time under a federal policy or program. For example, you may be entitled to more time because of a national emergency. However, if you fail to elect COBRA continuation coverage by the Due Date, you may be ineligible for COBRA continuation coverage.

    Send completed Election Form to:
    House Staff Benefits Plan
    10-27 46th Ave, Suite 300-2
    Long Island City, NY 11101
    (Email) benefits@cirseiu.org

    This Election Form must be completed and returned. If you don't submit a completed Election Form by the Due Date described above, you may lose your right to elect COBRA continuation coverage. If you reject COBRA continuation coverage before the Due Date, you may change your mind as long as you submit a completed Election Form before the Due Date. However, if you change your mind after first rejecting COBRA continuation coverage, your COBRA continuation coverage will begin on the date you submit the completed Election Form rather than the date you first became eligible for COBRA continuation coverage.

    Read the important information about your rights included in the pages after the Election Form.

  • COBRA Continuation Coverage Election Form

  • I (We) elect COBRA continuation coverage in the House Staff Benefits Plan (the Plan) listed below:
  • Based on your present insurance coverage, you are eligible for the following COBRA Continuation Coverage at the following monthly premium amount(s) (Please choose an option below and check the box to indicate that you are making an election): Insurance Benefits: Davis Vision Supplemental Benefits: Supplemental Major Medical & Supplemental Dental*
  • You should be aware that the price of COBRA Continuation Coverage is likely to change annually.
  • You should be aware that the price of COBRA Continuation Coverage is likely to change annually.*
    Rows
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Please check the applicable box(es) below to indicate the relationship between the employee and the individual(s) listed above:
  • HOUSE STAFF BENEFITS PLAN

    HOUSE STAFF BENEFITS PLAN

    LA General, LAC-Harbor-UCLA, MLK Hospital & Rancho Los Amigos Center
  • Format: (000) 000-0000.

  • Important Information About Payment

  • First payment for COBRA continuation coverage

    If you elect COBRA continuation coverage, you do not have to send any payment with the Election Form. However, if you do not submit payment in full for the first month of coverage at the time of election of coverage, your coverage will not be continued until payment is received. If no payment is received, your coverage will terminate as scheduled due to the Qualifying Event. You will have 45 days from the date that you timely elect coverage (the date the Election Form is submitted or if mailed, postmarked) to submit the payment in full for the first month of coverage. When payment in full is received or postmarked within 45 days from the date of election, or if applicable, the extended deadline date, coverage will be reinstated retroactively to the date that your coverage was terminated or is scheduled to terminate. If you don't make your first payment in full within 45 days after the date of your election, or if applicable, the extended deadline date, you'll lose all COBRA continuation coverage rights under the Plan. You're responsible for making sure that the amount of your first payment is correct. You may contact the Benefits Plan Office at benefits@cirseiu.org or (212) 356-8180 to confirm the correct amount of your first payment.
  • Periodic payments for continuation coverage

    After you make your first payment for COBRA continuation coverage, you'll have to make periodic payments for each coverage period that follows. The amount due for each coverage period for each qualified beneficiary is shown in this notice. The periodic payments can be made on a monthly basis. Under the Plan, each of these periodic payments for COBRA continuation coverage is due on or before the first of the month for that coverage period. If you make a periodic payment on or before the first day of the coverage period to which it applies, your coverage under the Plan will continue for that coverage period without any break. The Plan will not send periodic notices of payments due for these coverage periods.
  • Grace periods for periodic payments

    Although periodic payments are due on or before the first of the month for that coverage period, you'll be given a grace period of 30 days after the first day of the coverage period to make each periodic payment. You'll get COBRA continuation coverage for each coverage period as long as payment for that coverage period is made before the end of the 30-day grace period: if you pay a periodic payment later than the first day of the coverage period to which it applies, but before the end of the grace period for that coverage period, your coverage will be suspended as of the first day of the coverage period and then retroactively reinstated (going back to the first day of the coverage period) when the full periodic payment is received. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated. Payment by mail is considered made when postmarked.

    If you don't make a periodic payment before the end of the grace period for that coverage period, you'll lose all rights to COBRA continuation coverage under the Plan.
  • Your first payment and all periodic payments for COBRA continuation coverage should be sent to:

    House Staff Benefits Plan
    10-27 46th Ave, Suite 300-2
    Long Island City, NY 11101
  • All payments must be made by credit or debit card (American Express and Discover are not accepted).
    Please see the Credit Card Authorization Form enclosed.

  • COBRA CREDIT CARD AUTHORIZATION FORMHOUSE STAFF BENEFITS PLAN / VOLUNTARYHOSPITALS HOUSE STAFF BENEFITS PLAN

  • CREDIT/DEBIT CARD PAYMENT INFORMATION

  • Complete your payment selection: credit or debit card. American Express and Discover credit cards are not accepted.
  • Card Expiration Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Credit/Debit Card Type:
  • If you only need COBRA for a specific time period (e.g. one month or two months), list the date below in which you would like your benefits to end. Your COBRA benefits will terminate on the last day of the month for which a premium is paid.
  • Billing termination date (optional):
     - -
    2 digit month, 2 digit day, 4 digit year
  • By checking each box confirm you have read and understood the information below.*
  • By submitting this form, I certify all the information I have provided is accurate and complete. I understand that failure to provide complete and accurate information may result in the delay or denial of benefits. I understand the Plan reserves the right to request original receipts or any additional information.
  • Signature*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: