CERIDIAN BENEFITS SERVICES

3201 34th STREET SOUTH

ST PETERSBURG, FL 33711

IMPORTANT NOTICE OF NEW COBRA RIGHTS UNDER THE

AMERICAN RECOVERY AND REINVESTMENT ACT of 2009

The American Recovery and Reinvestment Act of 2009 (ARRA) provides “Assistance Eligible
Individuals” with a 65% reduction in the premiums for COBRA health care continuation
coverage for periods beginning February 17, 2009.

Please read the information contained in this notice very carefully to determine if you qualify for
the COBRA premium reduction under ARRA. If you qualify, you must complete the enrollment
and eligibility certification forms and submit them to Ceridian within 60 days from the date of this
notice to receive the COBRA premium reduction.

Do I qualify?
To be considered an “Assistance Eligible Individual” and receive the 65% COBRA premium
reduction, you must meet all three of the following conditions:

‰ Your COBRA election opportunity was due to an involuntary termination of employment

that occurred on or after September 1, 2008.
‰ You are or were eligible for COBRA coverage at any time on or after September 1, 2008
(whether you elected COBRA coverage initially or not).
‰ You are not eligible for Medicare or any other group health plan coverage (for example,
as a dependent on another family member’s plan or under a new employer’s plan).

Yes, I qualify. Now what?

If you meet all of the above conditions, the next step is to access and complete your enrollment
and eligibility certification forms. Ceridian will provide you with two options beginning April 20,
2009:

Option 1 How to access forms and enroll

Online You can enroll using the electronic forms by:
(preferred 1. Log on www.ceridian-benefits.com. For first time users:
method) o User ID: Your Social Security Number with the dashes
o Password: The last four digits of your Social Security Number
backwards (For example, if the last four digits are 1234, enter 4321)
2. Click the link: 2009 COBRA Change Information.
3. Click ARRA 2009 – Package 2
4. Complete online certification and enrollment.
Option 2 How to access forms and enroll
Paper You can request the forms by:
o Email: continuant.services@ceridian.com
o Mail: Ceridian Benefits Services
P.O. Box 534244
St. Petersburg, FL 33747-4244
o Phone: 1-800-877-7994 (Caution: See note below)
‰ For email or mail, use the subject line: “Requesting ARRA Forms”
L2v.2
 ‰ Provide the following information:
o Your name
o Account ID or Social Security Number
o Sponsoring employer’s name
‰ For email or phone, you can request the forms to be sent by email.
‰ For mail, Ceridian will mail the forms to you.
‰ Return completed forms by email or mail to Ceridian Benefits Services
(using our contact information in this option).

If you have questions about your rights to continuation coverage or about ARRA’s COBRA
provisions, detailed information is available on our Web site at www.ceridian-benefits.com.

The COBRA premium reduction is expected to help 7 million Americans maintain their health
insurance coverage. As a result, our COBRA Service Center is experiencing heavy call volume.
To avoid phone delays, we strongly encourage you to use our Web site or other non-
phone options for information. You can reach our Ceridian COBRA Service Center at
1-800-877-7994.

Remember, you have only 60 days from the date of this notice to complete and submit your
eligibility certification and enrollment to Ceridian to take advantage of the 65% COBRA premium
reduction under ARRA. You will have an additional 45 days from the date of your election to
pay your initial COBRA premium. If you do not do this, you will lose all continuation coverage
rights under the plan.

At Ceridian, we are committed to helping you understand your COBRA rights.

Sincerely,

Ceridian Benefits Services

L2v.2
 Summary of the COBRA Premium
Reduction Provisions under ARRA
President Obama signed the American Recovery and Reinvestment Act (ARRA) on February 17, 2009. The law gives
“Assistance Eligible Individuals” the right to pay reduced COBRA premiums for periods of coverage beginning on or
after February 17, 2009 and can last up to 9 months.

To be considered an “Assistance Eligible Individual” and get reduced premiums you:

¾ MUST be eligible for continuation coverage at any time during the period from September 1, 2008 through
December 31, 2009 and elect the coverage;
¾ MUST have a continuation coverage election opportunity related to an involuntary termination of employment
that occurred at some time from September 1, 2008 through December 31, 2009;
¾ MUST NOT be eligible for Medicare; AND
¾ MUST NOT be eligible for coverage under any other group health plan, such as a plan sponsored by a successor
employer or a spouse’s employer.

Individuals who experienced a qualifying event as the result of an involuntary termination of employment at any time
from September 1, 2008 through February 16, 2009 and were offered, but did not elect, continuation coverage OR who
elected continuation coverage and subsequently discontinued it may have the right to an additional 60-day election period.
i IMPORTANT i
¾ If, after you elect COBRA and while you are paying the reduced premium, you become eligible for other group
health plan coverage or Medicare you MUST notify the plan in writing. If you do not, you may be subject to a
tax penalty.

¾ Electing the premium reduction disqualifies you for the Health Coverage Tax Credit. If you are eligible for the
Health Coverage Tax Credit, which could be more valuable than the premium reduction, you will have received
a notification from the IRS.

¾ The amount of the premium reduction is recaptured for certain high income individuals. If the amount you earn
for the year is more than $125,000 (or $250,000 for married couples filing a joint federal income tax return) all
or part of the premium reduction may be recaptured by an increase in your income tax liability for the year. If
you think that your income may exceed the amounts above, you may wish to consider waiving your right to the
premium reduction. For more information, consult your tax preparer or visit the IRS webpage on ARRA at
www.irs.gov.

For general and specific information regarding your plan’s COBRA coverage, please visit our Web site www.ceridian-
benefits.com, or contact the COBRA Services Center by mail - 3201 34th Street South, St. Petersburg, Florida 33711.
For quick access to information, go to www.ceridian-benefits.com. You may also call 800-877-7994. Please note that
the COBRA Services Center is experiencing heavy call volume due to this new legislation. To avoid phone delays we
strongly encourage you to use the Web site if at all possible.

To notify Ceridian of your ineligibility to continue paying reduced premiums, mail the Notification of Ineligibility of
Premium Reduction form to: Ceridian COBRA Continuation Services, Attn: COBRA Benefits Administration, 3201 34th
Street South, St. Petersburg, Florida 33711. The form is provided to you in this package, and is also available on
www.ceridian-benefits.com.

If you are denied treatment as an “Assistance Eligible Individual” you may have the right to have the denial reviewed. For more
information regarding reviews or for general information about the ARRA Premium Reduction go to:
www.dol.gov/COBRA or call 1-866-444-3272

Generally, this does not include coverage for only dental, vision, counseling, or referral services; coverage under a health flexible
spending arrangement; or treatment that is furnished in an on-site medical facility maintained by the employer.

¾ See reverse side for important information

© 2009 Ceridian Corporation. All rights reserved.
RETRO
 Important Information About Your COBRA Continuation Coverage Rights
This notice contains important information about additional rights to continue your health care coverage under COBRA and
the COBRA Premium Subsidy. Please read the information contained in this notice very carefully.

The American Recovery and Reinvestment Act of 2009 (ARRA) reduces the COBRA premium in some cases. You are receiving this
notice because you experienced a loss of coverage at some time on or after September 1, 2008 and either chose not to elect COBRA
continuation coverage at that time OR elected COBRA but subsequently discontinued that coverage. If your loss of health coverage
was due to an involuntary termination of employment you may be eligible for a second COBRA election opportunity and the temporary
premium reduction for up to nine months. To help determine whether you can get the ARRA premium reduction, you should read this
notice and the attached documents carefully. In particular, reference the “Summary of the COBRA Premium Reduction Provisions
under ARRA” with details regarding eligibility, restrictions, and obligations and the “Assistance Eligible Individual Certification.” If you
believe you meet the criteria for the premium reduction, complete the “Assistance Eligible Individual Certification” and return
it with your completed Election Form.

Each person (“qualified beneficiary”) listed below, if an assistance eligible individual, is entitled to elect COBRA continuation coverage
which generally will continue group health care coverage under the Plan for up to 18 months after an involuntary termination of
employment.
x Employee or former employee
x Spouse or former spouse
x Dependent child(ren) covered under the Plan on the day before the involuntary termination of employment (and any new dependents born,
adopted, or placed for adoption on or after September 1, 2008).

If elected, COBRA continuation coverage will begin on the first coverage period beginning on or after February 17, 2009 (generally
March 1st) and can continue for up to a maximum of 18 months from the Qualifying Event Date.

COBRA continuation coverage generally costs 102% of the plan premium (COBRA premium). If you qualify as an “Assistance Eligible
Individual” this cost can be reduced to 35 percent of the COBRA premium for up to nine months. You do not have to send any
payment with the Election Form. Important additional information about payment for COBRA continuation coverage is included in this
notice.

If you have any questions about this notice or your rights to COBRA continuation coverage, you should contact Ceridian at the phone
number listed on your Important Notice.

Am I eligible to elect COBRA continuation Coverage at this time?

Only individuals who lost group health coverage due to an involuntary termination of employment on or after September 1, 2008, and
who did not elect COBRA continuation coverage during their first election period OR who elected but subsequently discontinued
COBRA coverage (for reasons other than becoming eligible for another group health plan or Medicare), are entitled to elect coverage at
this time.

Am I eligible for the premium reduction?

If you lost group health coverage due to an involuntary termination of employment on or after September 1, 2008 and are not eligible for
Medicare or other group health plan coverage, you are entitled to receive the premium reduction. Information about the amount of the
premium reduction and how it affects your premium payments can be found below under the question, “How much does COBRA
continuation coverage cost?”

How long will continuation coverage last?

Your coverage will begin retroactively on the first period of coverage on or after February 17, 2009, generally March 1 and can continue
for up to 18 months from the date of your involuntary termination of employment. The duration of the premium reduction is determined
separately and may not last for the entire length of your COBRA coverage. See the question below entitled “How much does COBRA
continuation coverage cost?”

Continuation coverage will be terminated before the end of the 18 month period if:
x any required premium is not paid in full on time,
x a qualified beneficiary becomes covered, after electing continuation coverage, under another group health plan that does not impose any pre-
existing condition exclusion for a pre-existing condition of the qualified beneficiary,
x a qualified beneficiary becomes entitled to Medicare benefits (under Part A, Part B, or both) after electing continuation coverage, or
x the employer ceases to provide any group health plan for its employees.

Continuation coverage may also be terminated for any reason the Plan would terminate coverage of a participant or beneficiary not
receiving continuation coverage (such as fraud).

How can you extend the length of COBRA continuation coverage?

If you elect continuation coverage, an extension of the maximum period of coverage may be available if a qualified beneficiary is
disabled or a second qualifying event occurs. You must notify Ceridian of a disability or a second qualifying event in order to extend the
period of continuation coverage. Failure to provide notice of a disability or second qualifying event may affect the right to extend the
period of continuation coverage.

© 2009 Ceridian Corporation. All rights reserved.

ARRA Summary – Retro – Page 1
Disability
If you or any other qualified beneficiary in your family who is receiving 18 months of continuation coverage is determined by the Social
Security Administration to be disabled and you notify Ceridian in writing in a timely fashion, you and your entire family may be entitled to
receive an additional 11 months of COBRA continuation coverage for a total maximum of 29 months. The disability would have to have
started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18 month period of
continuation coverage. The qualified beneficiary must provide the written determination of disability from the Social Security
Administration to Ceridian within 60 days of the latest of the date of the disability determination by the Social Security Administration,
the date of the initial qualifying event or the benefit termination date due to the initial qualifying event; and prior to the end of the 18
month COBRA continuation period. You will be required to pay up to 150 percent of the group rate during the 11 month extension. If the
qualified beneficiary is determined by the Social Security Administration to no longer be disabled, you must notify Ceridian of that fact
within 30 days after Social Security’s determination.

Second Qualifying Event

If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and
dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if
notice of the second qualifying event is properly given in writing to Ceridian within the later of 60 days of either the event or the date the
qualified beneficiary loses (or would lose) coverage under the Plan as a result of the event. This extension may be available to the
spouse and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to
Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible
under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the
Plan had the first qualifying event not occurred.

How can you elect COBRA continuation coverage?

You can elect COBRA continuation coverage and certify your eligibility at Ceridian’s website, www.ceridian-benefits.com, by calling the
automated telephone system at 1-800-877-7994 or by completing the enclosed Election Agreement and Assistance Eligible Individual
Certification Form and mailing to the address indicated. Each qualified beneficiary has a separate right to elect continuation coverage.
For example, the employee’s spouse may elect continuation coverage even if the employee does not. Continuation coverage may be
elected for only one, several, or for all dependent children who are qualified beneficiaries. A parent may elect to continue coverage on
behalf of any dependent children. The employee or the employee's spouse can elect continuation coverage on behalf of all of the
qualified beneficiaries.

In considering whether to elect continuation coverage, you should take into account that a failure to continue your group health
coverage will affect your future rights under Federal law. First, you can lose the right to avoid having preexisting condition exclusions
applied to you by other group health plans if you have a 63-day gap in health coverage, and election of continuation coverage may help
prevent such a gap. Second, you will lose the guaranteed right to purchase individual health coverage that does not impose a
preexisting condition exclusion if you do not elect continuation coverage for the maximum time available to you. If you do elect
continuation coverage under this additional election period, the period from qualifying event to the date coverage begins under your
election will not count as a break in coverage in determining whether you had a 63-day break in coverage.

How much does COBRA continuation coverage cost?

Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage. The amount a qualified
beneficiary may be required to pay may not exceed 102 percent (or, in the case of an extension of continuation coverage due to a
disability, 150 percent) of the cost to the group health plan (including both employer and employee contributions) for coverage of a
similarly situated plan participant or beneficiary who is not receiving continuation coverage.

The American Recovery and Reinvestment Act of 2009 (ARRA) reduces the COBRA premium in some cases. The premium reduction
is available to certain individuals who experience a qualifying event that is an involuntary termination of employment during the period
beginning with September 1, 2008 and ending with December 31, 2009. If you qualify for the premium reduction, you need only pay 35
percent of the COBRA premium otherwise due to the plan. This premium reduction is available for up to nine months. If your COBRA
continuation coverage lasts for more than nine months, you will have to pay the full amount to continue your COBRA continuation
coverage. See the attached “Summary of the COBRA Premium Reduction Provisions under ARRA” for more details, restrictions, and
obligations as well as the form necessary to establish eligibility.

The Trade Act of 2002 created a tax credit for certain individuals who become eligible for trade adjustment assistance and for certain
retired employees who are receiving pension payments from the Pension Benefit Guaranty Corporation (PBGC). Under the tax
provisions, eligible individuals can either take a tax credit or get advance payment of 65% of premiums paid for qualified health
insurance, including continuation coverage. ARRA made several amendments to these provisions, including an increase in the amount
of the credit to 80% of premiums for coverage before January 1, 2011 and temporary extensions of the maximum period of COBRA
continuation coverage for PBGC recipients (covered employees who have a non-forfeitable right to a benefit any portion of which is to
be paid by the PBGC) and TAA-eligible individuals.

If you have questions about these provisions, you may call the Health Coverage Tax Credit Customer Contact Center toll-free at
1-866-628-4282. TTD/TTY callers may call toll-free at 1-866-626-4282. More information about the Trade Act is also available at
www.doleta.gov/tradeact.

© 2009 Ceridian Corporation. All rights reserved.

ARRA Summary – Retro – Page 2
When and how must payment for COBRA continuation coverage be made?
If you elect continuation coverage, you do not have to send any payment with the Election Form. However, you must make your first
payment for continuation coverage not later than 45 days after the date of your election (this means within 45 days after the date your
Election Form is postmarked, if mailed). Upon receipt of your election by Ceridian, you will be billed for the first payment for continuation
coverage, which is the amount due from the first period of coverage on or after February 17, 2009 through the current month. If you do
not pay that amount in full within 45 days after the date of your election, you will lose all continuation coverage rights under the Plan
and your coverage will terminate. You are responsible for making sure that the amount of your first payment is correct. You may contact
Ceridian to confirm the correct amount of your payment.

After you make your first payment for continuation coverage, you will be required to make monthly payments for each subsequent
coverage period. The monthly invoice indicates a grace period measured from the due date for each monthly premium during which
payment may be made. The grace period is defined by the group health plan (usually 30 days). As noted, Ceridian will send monthly
invoices for each coverage period. However, remember that you are responsible for paying the full premium on time even if you do not
get an invoice. If you make a periodic payment on or before the first day of the coverage period to which it applies (the due date), your
coverage under the Plan will continue for that coverage period without any break. Although periodic payments are due on the first day
of each coverage period, you will be given a grace period (usually 30 days) to make each periodic payment. The grace period is defined
by the group health plan. Your continuation coverage will be provided for each coverage period as long as payment for that coverage
period is made before the end of the grace period for that payment. However, 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 the coverage period, your coverage under the Plan
may 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 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.

Your first payment and all periodic payments for continuation coverage should be made payable to “Ceridian COBRA Services” and
should be sent to Ceridian. Include the name and Acct ID#/Social Security number of the person covered on each check. Monthly
invoices are sent approximately 10 days before the premium due date. If full payment is not timely made (see below) on or before each
grace period expiration date, coverage will be cancelled and you will lose all rights to continuation coverage under the Plan.

What is a timely payment?

To be considered a timely payment, your premium payment must be either:
(1) Postmarked by the U.S. Postal Service on or before the applicable grace period expiration date, and received by Ceridian, or
(2) Sent by an express delivery service (such as Federal Express, UPS, etc.) — with proof of date sent from that service on or before
the applicable grace period expiration date, and received by Ceridian, or
(3) Delivered in person to a Ceridian representative during normal business hours at its offices on or before the grace period expiration
date.
Late payments cannot be accepted and will be returned, resulting in cancellation of your coverage with no possibility for reinstatement.

Note: Your premium is due on the “due date” shown on your invoice. If you wait until the end of the grace period to pay, you risk not
having sufficient time to correct errors which may or may not be within your control (such as unsigned checks, incorrect payment
amounts, premiums sent to the wrong address, or late/missed pickups by the U.S. Postal Service). In such cases, your coverage will be
cancelled with no possibility of reinstatement. For these reasons, we recommend that you send in your premium payment(s) prior to the
“due date.”

For more information

This notice does not fully describe continuation coverage or other rights under the Plan. More information about continuation coverage
and your rights under the Plan is available in your original COBRA election notice, the summary plan description, or from the Plan
Administrator. If you have questions concerning information contained in this Notice, contact Ceridian at the address and phone
number listed in this documentation. For a copy of your Summary Plan Description, or if you have questions concerning your Plan,
contact the Plan Administrator of your sponsoring employer.

For more information about rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and
other laws affecting group health plans, can contact the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA)
in your area or visit the EBSA website.

Keep Your Plan Informed of Address Changes

In order to protect your and your family’s rights, you should keep Ceridian informed of any changes and keep a copy of any notices you
send for your records.

© 2009 Ceridian Corporation. All rights reserved.

ARRA Summary – Retro – Page 3
To elect COBRA continuation coverage and apply for ARRA Premium Reduction, complete this form and return it with your
Election Form to: Ceridian COBRA Services Center
P.O. Box 534244
St. Petersburg, Florida 33747-4244

If you have already made an election for COBRA and wish to apply for ARRA Premium Reduction, complete this form and
return it to: Ceridian COBRA Benefits Administration
3201 34th Street South
St. Petersburg, Florida 33711

You may also want to read the important information about your rights included in the “Summary of the COBRA Premium
Reduction Provisions Under ARRA.”

ASSISTANCE ELIGIBLE INDIVIDUAL CERTIFICATION

PERSONAL INFORMATION Account ID or SSN

Name and mailing address (list any dependents on the back of this form) If you are a dependent, please provide employee SSN

Telephone number

E-mail address (optional)

To qualify, you must be able to check ‘Yes’ for all statements.*

1. The loss of employment was involuntary. … Yesҏ… No
2. The loss of employment occurred at some point on or after September 1, 2008 and on or before December 31, … Yesҏ… No
2009.
3. I elected (or am electing) COBRA continuation coverage.* … Yesҏ… No
4. I am NOT eligible for other group health plan coverage (or I was not eligible for other group health plan coverage … Yesҏ… No
during the period for which I am claiming a reduced premium).
5. I am NOT eligible for Medicare (or I was not eligible for Medicare during the period for which I am claiming a … Yesҏ… No
reduced premium).
*If you checked NO for statement 3, you may still be eligible. See below for more information.
*ADDITIONAL ELECTION PERIOD*
If your COBRA continuation coverage relates to an involuntary loss of employment on or after September 1, 2008 and you were eligible for, but did not
elect, COBRA continuation coverage OR you elected but subsequently discontinued COBRA, you may have the right to an additional 60-day election
period. An Election Form is enclosed which you MUST complete and return.
I make an election to exercise my right to the ARRA Premium Reduction. To the best of my knowledge and belief all of the answers I
have provided on this form are true and correct.

Signature __________________________________________________ Date ____________________________

Type or print name __________________________________________ Relationship to employee _________________________

FOR EMPLOYER OR PLAN USE ONLY
This application is: … Approvedҏ … Denied … Approved for some/denied for others (explain in #4 below)
Specify reason below and then return a copy of this form to the applicant.
REASON FOR DENIAL OF TREATMENT AS AN ASSISTANCE ELIGIBLE INDIVIDUAL
1. Loss of employment was voluntary. …
2. The involuntary loss did not occur between September 1, 2008 and December 31, 2009. …
3. Individual did not elect COBRA coverage.* …
4. Other (please explain) …

*If you checked number 3, was individual eligible for, and given, the Additional Election Period described above?
Signature of employer, plan administrator, or other party responsible for COBRA administration for the Plan

__________________________________________________ Date ____________________________

Type or print name _____________________________________________________________________________

Telephone number ____________________________ E-mail address ____________________________

See other side Æ

© 2009 Ceridian Corporation. All rights reserved.

COB4500/3/09
DEPENDENT INFORMATION (Parent or guardian should sign for minor children.) Employee SSN
Name Date of Birth Relationship to Employee SSN (or other identifier)

a. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage. … Yesҏ… No
2. I am NOT eligible for other group health plan coverage. … Yesҏ… No
3. I am NOT eligible for Medicare. … Yesҏ… No

I make an election to exercise my right to the ARRA Premium Reduction. To the best of my knowledge and belief all of the answers I
have provided on this form are true and correct.

Signature __________________________________________________ Date ____________________________

Type or print name __________________________________________ Relationship to employee _________________________

Name Date of Birth Relationship to Employee SSN (or other identifier)

b. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage. … Yesҏ… No
2. I am NOT eligible for other group health plan coverage. … Yesҏ… No
3. I am NOT eligible for Medicare. … Yesҏ… No

I make an election to exercise my right to the ARRA Premium Reduction. To the best of my knowledge and belief all of the answers I
have provided on this form are true and correct.

Signature __________________________________________________ Date ____________________________

Type or print name __________________________________________ Relationship to employee _________________________

Name Date of Birth Relationship to Employee SSN (or other identifier)

c. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage. … Yesҏ… No
2. I am NOT eligible for other group health plan coverage. … Yesҏ… No
3. I am NOT eligible for Medicare. … Yesҏ… No

I make an election to exercise my right to the ARRA Premium Reduction. To the best of my knowledge and belief all of the answers I
have provided on this form are true and correct.

Signature __________________________________________________ Date ____________________________

Type or print name __________________________________________ Relationship to employee _________________________

________________________________________________________________________________
Name Date of Birth Relationship to Employee SSN (or other identifier)

d. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage. … Yesҏ… No
2. I am NOT eligible for other group health plan coverage. … Yesҏ… No
3. I am NOT eligible for Medicare. … Yesҏ… No

I make an election to exercise my right to the ARRA Premium Reduction. To the best of my knowledge and belief all of the answers I
have provided on this form are true and correct.

Signature __________________________________________________ Date ____________________________

Type or print name __________________________________________ Relationship to employee _________________________

© 2009 Ceridian Corporation. All rights reserved.

COB4500/3/09
 Continuation of Health Coverage Election Agreement (COBRA)
COBRA PARTICIPANT INFORMATION
Individual’s Last Name First Name MI Gender

… Male … Female
Social Security # ___ ___ Date of Birth (mmddyyyy) Daytime Telephone # (include Area
Code)

Mailing Address: Street (include apt. #) or P O Box

City State Zip Code (+ 4)

Email address Sponsoring Employer If you are a dependent, electing coverage

independently, enter the employee SSN

COVERAGE ELECTION
You must enter all Coverage Type(s) you wish to elect. You can only elect coverage that was in effect at the time of your Qualifying Event. Election
of options not available to you will not be processed.

Coverage Type Family Status

… Medical … Individual … Individual + Spouse … Individual + Child(ren) … Individual + Spouse + Child(ren)

… Dental … Individual … Individual + Spouse … Individual + Child(ren) … Individual + Spouse + Child(ren)

… Vision … Individual … Individual + Spouse … Individual + Child(ren) … Individual + Spouse + Child(ren)

… Prescription … Individual … Individual + Spouse … Individual + Child(ren) … Individual + Spouse + Child(ren)

… Other (EAP, … Individual … Individual + Spouse … Individual + Child(ren) … Individual + Spouse + Child(ren)
HRA, etc.)

… FSA If you are/were enrolled in an FSA plan in the current plan year and wish to continue, please check the box.
The COBRA premium subsidy does not apply to a Healthcare Flexible Spending Account.
COBRA Coverage Effective Date
… No Gap in Coverage (this option is available if within initial 60 day COBRA … GAP in Coverage (applies if not within initial 60 day election
election period and coverage terminated prior to 2/16/09). Pay the full COBRA period and coverage terminated prior to 2/16/09). Pay 35% of
premium retroactively until the Premium Reduction starts. Then pay 35% of COBRA premium for the coverage period on or after the
COBRA premium for the coverage period on or after the enactment date of enactment date of 2/17/09.
2/17/09.

DEPENDENTS
Coverage Type
Last Name First Name Relationship SSN (xxx-xx-xxx) Date of Birth
Med Den Vis RX Other

YOUR CERTIFICATION
I authorize the benefit election I have indicated above. I certify that I am electing only those coverages that were in effect on the day before the Qualifying
Event, and that I understand that I will no longer be eligible for COBRA continuation coverage if I become entitled to Medicare or become covered under
another group health plan that does not contain a limitation or exclusion due to a pre-existing condition. I further certify that all information is complete and
accurate to the best of my knowledge.
Your Signature Date

Return form to: Ceridian COBRA Services Center The completed Election Agreement must be sent by the
P.O. Box 534244 Election Expiration Date indicated in the “Important
St. Petersburg, Florida 33747-4244 Notice”.
COB4000/3/09
You Have Options ...

Option #1 - ELECT BY NET

s,OGONTOOUR7EBSITEATWWWCERIDIAN BENElTSCOM
s%NTERYOURLOGINNAME)FTHISISYOURINITIALLOGINPLEASEENTERYOUR3OCIAL3ECURITYNUMBER IMPORTANT:
(SSN) with the dashes (XXX-XX-XXXX) as your login name. Do Not Submit the
enclosed Election Agreement if you
s%NTERYOUR0).NUMBER)FTHISISYOURINITIALLOGINENTERTHELASTDIGITSOFYOUR33. ELECT BY NET or
backwards as your PIN. ELECT BY PHONE.
s&OLLOWTHEEASYINSTRUCTIONS

Option #2 - ELECT BY PHONE

If you do not have access to a computer or wish to avoid completing the accompanying
COBRA Election Form, you may call the number on your "Important Notice" and Elect By TWO-KEY ENTRY KEYPAD CHART
Phone! ABC DEF A = 21 N= 62
1 2 3 B = 22 O= 63
During the Election Process ... you may be prompted to provide dependent information GHI JKL MNOO C = 23 P = 71
4 5 6
using the TTwo-Key method as described below: D = 31 Q= 01
PRS TUV WXYY
7 8 9
E = 32 R= 72
‡ Press two keys for each letter of the first name. The first key is the letter you wish to enter. F = 33 S = 73
OPER
* 0 # G = 41 T = 81
Take a moment to list your dependents and H = 42 U= 82
Example: Mary needs I = 43 V = 83
their keypad equivalents before you call: to continue coverage J = 51 W= 91
for her son, Jon, as a K = 52 X = 92
dependent in her health L = 53 Y = 93
Name J O N M = 61 Z = 02
Keypad 51 6 3 6 2 care coverage.
space = 11
Name For the letter J; ...... 51 hyphen = 12
Keypad for the letter O; ....... 63 apostrophe = 13
Name for the letter N; ....... 62 Please Note:
Two numbers must be
Keypad end with the # key.....# entered for each letter.

Additional Information regarding ELECT BY NET and ELECT BY PHONE:

‡ ELECT BY NET requires either Microsoft Internet Explorer software, version 5.0 or higher.
‡ ELECT BY NET and ELECT BY PHONE have been programmed to NOT accept an election within 2 days of the COBRA election
expiration date. If you are within 2 days of the COBRA expiration date, you must fill out and mail in your Election Agreement.
‡ ELECT BY PHONE requires that you currently reside at the same address as shown on the COBRA Notification letter and you
want exactly the same coverage(s) for the same covered dependents that were in effect the day before your Qualifying Event.
This same coverage includes Flexible Spending Account, if you have one.
‡ There are a few other rare instances when ELECT BY NET and ELECT BY PHONE may direct you to fill out and send in your
Election Agreement.
‡ Even if your election by the Internet or telephone is successful, we recommend you keep your COBRA Election Form until you
receive an invoice (approximately 3-5 days) confirming your election.

Option #3 - ELECT BY PAPER (Form)

Please complete the Election Agreement on the next page to “Elect By Paper.” Mail the completed Election Agreement to the address indicated on
the bottom of the form.

Questions? Call our Customer Service Center at the number indicated on your ,PSRUWDQW 1RWLFH

About the Premium Reduction
1. How much is the
premium reduction?
2. Because I received this
letter, does this mean I
qualify for the premium
reduction?
3. What plans are eligible
for the premium
reduction?
4. How long can I receive
the premium reduction?
About Qualifying
5. How much time do I have
to respond?
6. What happens if I do not
respond?
7. I cancelled my COBRA
coverage. Can I qualify
for the premium
reduction?
After Qualifying
8. If I qualify, when can I
expect to receive the
premium reduction and
any credit or
reimbursement?
9. If I qualify, will I receive
the premium reduction
on payments I have
already made?
10. How do I notify Ceridian
if I become ineligible for
the COBRA premium
reduction?
More information
COBRA Premium Reduction - Frequently Asked Questions
The premium reduction is 65% of the total premium for which eligible individuals are responsible to
pay.
No. Not everyone who receives this notice qualifies for the premium reduction. To determine if you
qualify for the premium reduction, review the guidelines and follow the steps provided in this package.
Ceridian has mailed this letter to all qualified beneficiaries who experienced a COBRA qualifying event
on or after September 1, 2008 and through December 31, 2009, but only those qualified beneficiaries
that originally lost coverage under the group health plan as a result of an involuntary termination within
the above dates may be eligible for premium reduction. The definition includes newborns or adopted
children of the former employee added during the period of COBRA coverage..
The premium reduction applies to all COBRA eligible plans. This includes: Medical, Dental, Vision,
Prescription, HRA and EAP plans.
Note: Flexible Spending Accounts (FSA) are not eligible for the premium reduction.
Your premium reduction can last up to 9 months. However, this reduction will end earlier if:
x You become eligible for Medicare or another group health plan (such as a plan sponsored by a
new employer or a spouse’s employer),
x You reach the end of your maximum COBRA coverage period.
Note: See Question 10 for details on what to do if you become ineligible after qualifying.
If you were previously offered COBRA, and did not elect or you elected and subsequently
cancelled, you have a special 60-day election period to elect the COBRA premium reduction.
However, you must meet the eligibility criteria. If you do not meet the eligibility criteria, you will be
denied COBRA continuation coverage.
If this is your first opportunity to elect COBRA, you have 60 days from the date we send you your
COBRA & ARRA Notification to elect COBRA coverage. If you are not qualified to receive the reduced
premium, you can still elect COBRA at the full cost of the plan.
If you are receiving COBRA, Ceridian will continue to bill you as usual. If you are not receiving
COBRA and do not want coverage, you do not need to respond.
You are eligible for the premium reduction program and may re-enroll in COBRA with the premium
reduction if you:
1. Lost group health coverage because of involuntary termination on or after September 1, 2008
2. Meet all eligibility criteria
x Ceridian will update invoices and accounts in approximately 30 days after receiving your certified
premium reduction information.
x Until the premium reduction appears on your invoice, you need to pay the full invoice.
x After the 30 days, Ceridian will credit (or reimburse if necessary) your account for overpayments.
You will not receive credit or reimbursements of payments for coverage periods prior to February 17,
2009. Ceridian will credit or reimburse those who qualify for the premium reduction. However, the
premium reduction is applicable beginning with the first period of coverage after February 17, 2009
(or generally, beginning with the March 1, 2009 COBRA premium).
Complete the Participant Notification of Ineligibility for Premium Reduction form on the back of this
form, if you are no longer eligible for the COBRA premium reduction. Mail the form to:
Ceridian COBRA Continuation Services
Attn: COBRA Benefits Administration
3201 34th Street South
St. Petersburg, Florida 33711
Note: Individuals paying reduced COBRA premiums must notify their plans if they become eligible for
coverage under another group health plan or Medicare. Failure to do so can result in a penalty of
110% of the subsidy actually received.
www.ceridian-benefits.com 800.877.7994 – the automated telephone system: Available 24/7
Call Center support: Monday to Friday - 8:00 AM to 8:00 PM ET
(Please note that the COBRA Services Center will be
experiencing heavy call volume due to this new legislation.)
Note: You must complete your certification online, on the automated telephone system, or by mail.
© 2009 Ceridian Corporation. All rights reserved.
 Please retain this form with your COBRA records.
Send this form to Ceridian only if you become ineligible to receive the COBRA premium reduction. Please complete
all information requested on this form and mail to:
th
Ceridian COBRA Continuation Services, Attn: COBRA Benefits Administration, 3201 34 Street South, St. Petersburg, FL 33711

Participant Notification of Ineligibility for Premium Reduction

Sponsoring Employer Name: Ceridian COBRA
Use this form to notify Ceridian that you are Continuation
eligible for other group health plan coverage Services
Attn: COBRA Benefits
or Medicare and therefore not eligible for Administration
th
3201 34 Street South
Please write sponsoring
reduced premiums under ARRA. St. Petersburg, FL 33711
employer’s name above
PERSONAL INFORMATION – Please complete all information.
Name: _______________________________________________ Telephone number
Address: _______________________________________________
_______________________________________________
_______________________________________________
E-mail address (optional)
Account ID (or SSN): ______________________________________

PREMIUM REDUCTION INELIGIBILITY INFORMATION – Check one

I am eligible for coverage under another group health plan.

If any dependents are also eligible, include their names below.
…ҏ
Insert date you became eligible______________________

I am eligible for Medicare.

…ҏ
Insert date you became eligible______________________

IMPORTANT
If you fail to notify your plan of becoming eligible for other group health plan coverage or Medicare AND continue to
pay reduced COBRA premiums you could be subject to a fine of 110% of the amount of the premium reduction.

Eligibility is determined regardless of whether you take or decline the other coverage.

However, eligibility for coverage does not include any time spent in a waiting period.

To the best of my knowledge and belief all of the answers I have provided on this Form are true and correct.

Signature __________________________________________________ Date ____________________________

Type or print name _____________________________________________________________________________

If you are eligible for coverage under another group health plan and that plan covers dependents you must also list their
names here:

_________________________________________ _________________________________________

_________________________________________ _________________________________________

© 2009 Ceridian Corporation. All rights reserved.

Form COB4800/3/09