NOTE: This notice must be customized according to your company's plan particulars and the specific circumstances. The notice must explain why an individual is not entitled to COBRA continuation of coverage (29 C.F.R. 2590.606-4(c)). The plan administrator must provide the notice within 14 days after receiving a notice of qualifying event from a participant, beneficiary or other individual (29 C.F.R. 2590.606-4(b)(2)).
[Date of notice]
[Name]
[Mailing address]
Dear [Name],
[Name of COBRA administrator] has received your request for COBRA continuation coverage through [Company name]'s group health care plan.
We have determined that COBRA continuation coverage is unavailable to you and your covered dependents for the following reason(s):
[Insert a description of the reason for unavailability of COBRA coverage]
If you have questions or wish to appeal this decision, please contact [COBRA administrator's name and contact information] for assistance.
Sincerely,
[Name]
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