make separate elections, and only the persons listed on that election form as being covered by continuation coverage will be covered.

Additional dependent children. A child who is born or placed for adoption with a covered former employee during a period of continuation coverage is a “qualified beneficiary” who has the same rights to continuation coverage as a child born to the employee or placed for adoption with the employee before the employee’s qualifying event. Such children can be added for coverage subject to any late enrollment or preexisting condition rules that otherwise apply under the plan.

Your responsibility to notify the plan. Under the law, the employee or a family member has the responsibility to inform the plan representative named at the end of this notice of: (i) a divorce, legal separation, or a child losing dependent status under the plan, or (ii) a determination that an employee, spouse, or dependent child has been determined to be disabled for Social Security purposes. You must provide this notice within 60 days of such an event. Failure to notify the plan representative in a timely manner of the event will result in the loss of the right to elect or extend continuation coverage, as applicable. An employee, spouse, or dependent child who has been determined to be disabled must notify the plan representative within 30 days of a final determination that he or she is no longer disabled. The City has the responsibility to notify the plan representative if the applicable event is the employee’s death, termination of employment or reduction in hours, or Medicare entitlement.

When the plan will provide further notice of COBRA rights. When the plan representative is notified that a divorce, a legal separation, a child losing dependent status under the plan, the employee’s death, the employee’s termination of employment (other than for gross misconduct), or the employee’s reduction in hours has happened, the plan representative will, in turn, notify you that you have the right to choose continuation coverage. Under the law, you have at least 60 days from the date you would lose coverage because of one of the events described above to inform the plan representative that you want continuation coverage. If you do not choose continuation coverage, your group medical, dental, and/or vision coverage will end.

Type of continuation coverage available. If you choose medical, dental, and/or vision continuation coverage, the plan is required to give you coverage which, as of the time coverage is being provided, is identical to the medical, dental, and/or vision coverage provided at that time under the plan to similarly situated employees or family members.

Maximum duration of coverage. The law requires that you be afforded the opportunity to maintain continuation coverage for up to 3 years after the event which is the reason for the loss of coverage unless you lost group coverage because of a termination of employment (other than for gross misconduct) or reduction in hours of the applicable employee. In that case, the required continuation coverage period, for both the employee and any eligible family members of the employee, is up to 18 months.

Multiple qualifying events. The initial 18-month period (if it applies) may be extended for a spouse or dependent child (but not for an employee) for up to an additional 18 months if another event which would otherwise cause a loss of coverage for the spouse or