COBRA Notices

To protect your and your qualified beneficiaries' right to elect COBRA, please use the following forms to notify the Plan of your COBRA qualifying event.

If the qualifying event is a divorce or legal separation, your notice must include a copy of the decree of divorce or legal separation. If your coverage is reduced or eliminated and later a divorce or legal separation occurs, and if you are notifying us that your Plan coverage was reduced or eliminated in anticipation of the divorce of legal separation, your notice must include evidence satisfactory to us that your coverage was reduced or eliminated in anticipation of the divorce or legal separation.

1. the name and address of the disabled qualified beneficiary;
2. the date that the qualified beneficiary became disabled;
3. the names and addresses of all qualified beneficiaries who are still receiving COBRA coverage;
4. the date that the Social Security Administration made its determination;
5. a copy of the Social Security Administration's determination; an
6. a statement whether the Social Security Administration has subsequently determined that the disabled qualified beneficiary is no longer disabled.

1. the names and addresses of all qualified beneficiaries who are still receiving COBRA coverage;
2. the second qualifying event and the date that it happened; and
3. if the second qualifying event is a divorce or legal separation, a copy of the decree of divorce or legal separation.

How, when and where to send notices
You must mail or hand-deliver your notice to:
COBRA Plan Administrator
Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
Human Resources J1-105
P.O. Box 19024
Seattle, WA 98109-1024

If mailed, your notice must be postmarked no later than the last day of the applicable notice period. If hand-delivered, your notice must be received by the COBRA Plan Administrator at the address specified above no later than the last day of the applicable notice period. The applicable notice periods are described in the paragraphs entitled "You must give notice of some qualifying events," Disability extension of COBRA coverage," and "Second qualifying event extension of COBRA coverage" in the General Notice of COBRA Continuation Coverage Rights document: FHCRC or SCCA.

Who may provide notices: The covered employee (i.e., the employee or former employee who is or was covered under the Plan), a qualified beneficiary who lost coverage due to the qualifying event described in the notice, or a representative acting on behalf of either may provide notices. A notice provided by any of these individuals will satisfy any responsibility to provide notice on behalf of all qualified beneficiaries who lost coverage due to the qualifying event described in the notice.