ࡱ> `b]^_%` xbjbj"x"x N@@MJzzz  T d```4abt:cpddddssL1t($!hj̸ fvoLsfvfv̸l l dd X|X|X|fvl Rd dX|fvX|X|ߪ# " dc h`w,0.l6xrX HYtvtTX|#uDguYtYtYt̸̸yYtYtYtfvfvfvfvttt$,JtttJ4 T  Th l l l  Model COBRA Continuation Coverage Supplemental Notice (For use by group health plans for qualified beneficiaries currently enrolled in COBRA coverage with qualifying events that occurred on or after September 1, 2008 to advise them of the availability of the premium reduction.) [Enter date of notice] Dear: [Identify the qualified beneficiary(ies), by name or status] This notice contains important information about additional rights you may have related to your COBRA continuation coverage in the [enter name of group health plan] (the Plan). 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 chose to elect COBRA continuation coverage. If your loss of health coverage was due to an involuntary termination of employment you may be eligible for 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 Application for Treatment as an Assistance Eligible Individual. If you believe you meet the criteria for the premium reduction, complete the Application for Treatment as an Assistance Eligible Individual and return it to us at [insert mailing address]. [If the plan permits Assistance Eligible Individuals to elect to enroll in coverage that is different than coverage in which the individual was enrolled at the time the qualifying event occurred, insert: To change the coverage option(s) for your COBRA continuation coverage to something different than what you had on the last day of employment, complete the Form for Switching COBRA Continuation Coverage Benefit Options and return it to us. Available coverage options are: [insert list of available coverage options]. The different coverage must cost the same or less than the coverage the individual had at the time of the qualifying event; be offered to active employees; and cannot belimited to only dental coverage, vision coverage, counseling coverage, a flexible spending arrangement (FSA), including a health reimbursement arrangement that qualifies as an FSA, or an on-site medical clinic. ] Important Information about Your COBRA Continuation Coverage Rights 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 required payment for each continuation coverage period for each option is described in this notice. 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. [If employees might be eligible for trade adjustment assistance, the following information must be added: 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 nonforfeitable 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  HYPERLINK "http://www.doleta.gov/tradeact" www.doleta.gov/tradeact.] When and how must payment for COBRA continuation coverage be made? Other than the amount, nothing else about the payment has changed. All periodic payments for continuation coverage should be sent to: [enter appropriate payment address] You may contact [enter appropriate contact information, e.g., the Plan Administrator or other party responsible for COBRA administration under the Plan] to confirm the correct amount of your first payment or to discuss payment issues related to the ARRA premium reduction. 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 any questions concerning the information in this notice, your rights to coverage, or if you want a copy of your summary plan description, you should contact [enter name of party responsible for COBRA administration for the Plan, with telephone number and address]. Private sector employees seeking 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 Labors Employee Benefits Security Administration (EBSA) at 1-866-444-3272 or visit the EBSA website at  HYPERLINK "http://www.dol.gov/ebsa" www.dol.gov/ebsa. State and local government employees should contact HHS-CMS at  HYPERLINK "http://www.cms.hhs.gov/COBRAContinuationofCov/" www.cms.hhs.gov/COBRAContinuationofCov/ or  HYPERLINK "mailto:NewCobraRights@cms.hhs.gov" \o "mailto:NewCobraRights@cms.hhs.gov" NewCobraRights@cms.hhs.gov. Keep Your Plan Informed of Address Changes In order to protect your and your familys rights, you should keep the Plan Administrator informed of any changes in your address and the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. [Only use this model form if the plan permits Assistance Eligible Individuals to elect to enroll in coverage that is different than coverage in which the individual was enrolled at the time the qualifying event occurred.] Form for Switching COBRA Continuation Coverage Benefit Options  I (We) would like to change the COBRA continuation coverage option(s) in the [enter name of plan] (the Plan) as indicated below: Name Date of Birth Relationship to Employee SSN (or other identifier) a. _________________________________________________________________________ Old Coverage Option:____________________________ New Coverage Option: __________________________ b. _________________________________________________________________________ Old Coverage Option:____________________________ New Coverage Option: __________________________ c. _________________________________________________________________________ Old Coverage Option:____________________________ New Coverage Option: __________________________ _____________________________________ _____________________________ Signature Date ______________________________________ _____________________________ Print Name Relationship to individual(s) listed above ______________________________________ ______________________________________ ______________________________________ ______________________________ Print Address Telephone number  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: MUST be eligible for continuation coverage at any time during the period from September 1, 2008 through December 31, 2009 and elect the coverage; 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; MUST NOT be eligible for Medicare; AND MUST NOT be eligible for coverage under any other group health plan, such as a plan sponsored by a successor employer or a spouses 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. ( IMPORTANT ( % 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. % 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. % 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  HYPERLINK "file:///\\\\www.irs.gov" \o "file://www.irs.gov/" www.irs.gov. For general information regarding your plans COBRA coverage you can contact [enter name of party responsible for COBRA administration for the Plan, with telephone number and address]. For specific information related to your plans administration of the ARRA Premium Reduction or to notify the plan of your ineligibility to continue paying reduced premiums, contact [enter name of party responsible for ARRA Premium Reduction administration for the Plan, with telephone number and address]. 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:  HYPERLINK "http://www.dol.gov/COBRA" www.dol.gov/COBRA or call 1-866-444-EBSA (3272) To apply for ARRA Premium Reduction, complete this form and return it to: [Enter Name and Address] You may also want to read the important information about your rights included in the Summary of the COBRA Premium Reduction Provisions Under ARRA. [Insert Plan Name]REQUEST FOR TREATMENT AS AN ASSISTANCE ELIGIBLE INDIVIDUAL[Insert Plan Mailing Address] PERSONAL INFORMATION Name and mailing address of employee (list any dependents on the back of this form)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.( Yes ( No2. The loss of employment occurred at some point on or after September 1, 2008 and on or before December 31, 2009.( Yes ( No3. I elected (or am electing) COBRA continuation coverage.*( Yes ( No4. I am NOT eligible for other group health plan coverage (or I was not eligible for other group health plan coverage during the period for which I am claiming a reduced premium).( Yes ( No5. I am NOT eligible for Medicare (or I was not eligible for Medicare during the period for which I am claiming a reduced premium).( Yes ( No*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 from September 1, 2008 through February 16, 2009 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. You should receive a new election notice with an Election Form which you MUST complete and return. If you believe you should have received this additional notice but have not, contact [enter name of party responsible for COBRA administration for the Plan, with telephone number and address]. 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: ( Approved ( 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 INDIVIDUAL1. 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 ____________________________  DEPENDENT INFORMATION (Parent or guardian should sign for minor children.) Name Date of Birth Relationship to Employee SSN (or other identifier) a. _________________________________________________________________________ 1. I elected (or am electing) COBRA continuation coverage.( Yes ( No2. I am NOT eligible for other group health plan coverage.( Yes ( No3. I am NOT eligible for Medicare.( Yes ( 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.( Yes ( No2. I am NOT eligible for other group health plan coverage.( Yes ( No3. I am NOT eligible for Medicare.( Yes ( 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.( Yes ( No2. I am NOT eligible for other group health plan coverage.( Yes ( No3. I am NOT eligible for Medicare.( Yes ( 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 _________________________ This form is designed for plans to distribute to COBRA qualified beneficiaries who are paying reduced premiums pursuant to ARRA so they can notify the plan if they become eligible for other group health plan coverage or Medicare. Use this form to notify your plan that you are eligible for other group health plan coverage or Medicare. Plan Name Participant NotificationPlan Mailing Address  PERSONAL INFORMATIONName and mailing address Telephone number E-mail address (optional)PREMIUM REDUCTION INELIGIBILITY INFORMATION Check oneI am eligible for coverage under another group health plan. If any dependents are also eligible, include their names below. Insert date you became eligible______________________ ( 6V   / 9 s t u  ( n p S v   H I ͲͲԉh?^%h; 5hb,h; 5 hvwh; hvw hr4h; hr4hbS h2h; h; h :h; 56\]h :h; 6] h :h; h; 5hh; 5 h; 5\h :h; 5\jh5UmHnHu18  1 2 u v o p JKLNO gd; gd; $a$gdQ2/gdQ2/gd; $a$gd; tv &1GIJLM'/ ,WYJLkzpibpZh!vhQ2/5 hvw56 hCVM56h!vhQ2/56h!vhQ2/5CJhQ2/56CJ hQ2/56hvwhQ2/5hehQ2/5 hQ2/5CJhehQ2/5CJhehQ2/0J56hehQ2/0J5 hQ2/5hQ2/ h; 5\h5h; 56 h; 5h?^%h; 5hvwh; 5 hvw5MN2DFJSTU'Eqr»~wog` hvh; jh; Uh3B*ph h3h3 h3,6]h :h; 6]hK hDh; h^h; h2h; h :h; >*PJh :h; >* h :h; $hiLh; 56;CJPJ]aJhiLh; 5CJaJhQ2/5CJaJhhQ2/5PJh!vhQ2/0J56% !"gf '!+!K!!!R"c""""""""""""7#ƼƼƸƸƼƴƩƩߘ hzhwjhzhwU hzhM7 hzh; h :h; 0J>*jh :h; Uh^hh\bh :h; 6] h :h; h :h; >*PJh :h; >*h; h h; 0Jjh; Ujh; U/!"  *!+!##$$%%%2&4&5&6&7& d`gd;  gd; gd; gd; 7#8#9#`#a#e#f########$%%%4%%%%%%%%%&1&2&3&?&F&^&{&&ƻƲƻ֫xpkpkpX$jh :hKCJUmHnHu h; 5h@h; 5 hxxh; hW;h; 6 h; 6h@h; 6h; h; 5CJ aJ h :h; 5\ h :h; hzhX|0JhzhX|B* phjhzhX|B* Uph hzhM7hzhw0JjhzhwUjhzhwU"7&8&9&:&;&<&=&>&?&&&'']''' (<(l((())h)|) dh`gd; dhgd;  hT@ dgd; gd; &&&&&&&'']'k'p'' (((((k(((((()))))G************¯{okh5h5hM75CJ aJ hM75CJ aJ h5jshM75CJ aJ h5h55CJ aJ %jh55CJ UaJ mHnHu%jh"5CJ UaJ mHnHuhD5CJ aJ hh; CJ aJ hTh; CJaJh; h :h; 5\h :h; 6] h :h; (|)})))) *G********* , ,^,_,,- & F HH^HgdM7gdM7$a$gdM7$a$gdJdhgd; P^`Pgd; gd; *++ ,^,s,t,,,,,,-)-3-M-|-}------------.^._.a.~......../ /,/9/Q/f/x//////////00j111Ľ hM75 jhM75h@`hM75CJ aJ hv$~hM75 hv$~hphphM7B*phhv$~hM7B*ph j*hv?hM70J h[ hM7 hohM7hM7 hv$~hM7=--`.a.////1133]6^677M8N80999gdZgd5 H^H`gdM7$a$gdM7gdM7 & F7$8$H$gdM7 & F7$8$H$gdM71133566N6O6Z6[6]6^66777 8 88J8M8N8888)9.90919W9X9Y9j9k9999ǽǽ񢚈{plhJh+hM7CJaJh hM70JCJaJ#j*h hM7CJUaJhM7CJaJjhM7CJUaJ hM76]hv$~hM76hv$~hM76] hv$~hM7hM7CJaJhulOhM70JjhulOhM7U hulOhM7hM7h@`hM7CJ aJ %9999999F:G::::::::::쟋wfZJZ;h+hJCJOJQJ^Jh$hJ6CJOJQJ^Jh$CJOJQJ^J h+hJCJOJQJ^JaJ&h$hJ5CJOJQJ\^JaJ&h$hB5CJOJQJ\^JaJ h$5CJOJQJ\^JaJ&h+hJ5CJ OJQJ\^JaJ ,h+hJ56CJOJQJ\]^JaJ hK5CJOJQJ\^JaJ&h+hJ5CJOJQJ\^JaJ999::::: $$Ifa$gd0XgdJ&$d%d&d'dNOPQgdJ:::::::: ; ; ;1;_;r;s;;;;;;;<<<<V<նziWWGh+hJ5OJQJ\^J" jh+hJCJOJQJ^J h+hJCJOJQJ^JaJ h+hJCJOJQJ^JaJh+hJ5>*OJQJ^Jh+hJ>*OJQJ^Jh+hJOJQJ^Jh+hJCJOJQJ^Jh$hJ6CJOJQJ^Jh$CJOJQJ^Jh+hJ5CJOJQJ^Jh+hJ5OJQJ^J:: ;ul $Ifgd0Xkd$$Ifl4      qF G" + o  0      ,    4 la|f4 ; ;`;r; $If^gd0X h$If^hgd0Xakd$$Ifl4       +, 0      ,4 la|f4r;s;t;;r $If^gd0X $Ifgd0Xvkd$$Ifl4      0 +`K0      ,4 la|f4;;;| $$Ifa$gd0XvkdI$$Ifl4      0 + K0      ,4 la|f4;;;< $Ifgd0Xakd $$Ifl4       +, 0      ,4 la|f4<<< =qh $Ifgd0XS$If^`Sgd0X|kd$$Ifl      0D% +4&0      ,2 s2 s4 la|V<<<<<<== =========???????$?$@&@(@2@4@<@>@N@@@A:Aⴓtb#h+hJ5CJOJQJ^JaJh+hJOJQJ^J"h+h,5CJOJQJ\^J"h+hJ5CJOJQJ\^Jh+h=CJOJQJ^Jh+hJ5OJQJ\^J" jh+hJCJOJQJ^Jh{CJOJQJ^Jh+hJCJOJQJ^Jh+h-0CJOJQJ^J$ ====yy $Ifgd0X|kd[$$Ifl      0D% +4&0      ,2 s2 s4 la|==??yy $Ifgd0X|kd$$Ifl      0D% +4&0      ,2 s2 s4 la|??&@<@yy $Ifgd0X|kd$$Ifl      `0D% +4&0      ,2 s2 s4 la|<@>@@y $Ifgd0X|kdb $$Ifl      0D% +4&  0      ,2 s2 s4 la|@A:A*CJOJQJ^Jh+hJCJOJQJ^J6jh+hJ5CJOJQJU\^JmHnHuEEEF8G:GG $$Ifa$gd0XckdO $$Ifl4      g +,0      ,4 la|f4FFF F*F,F.FF G G6G8G:GGGGHHaHbHgHqHHH͚͈vgZgHgHg*CJOJQJ^Jh+h'CJOJQJ^Jh'CJOJQJ^Jh'>*CJOJQJ^J0jh+ha=CJOJQJU^JmHnHu*jh'CJOJQJU^JmHnHu0jh+ha=CJOJQJU^JmHnHuh+ha=CJOJQJ^Jh+ha=>*CJOJQJ^JJJJJJJKKcKdKKuee]]dhgdJ hT@ dgdt &d P gdBgdBgdJskd$$Ifl4      & +,  0      ,4 la|f4p JJJKKKKKKL L LLLLLLLLLMMNN9N:NȻ|pW0jh'hJCJOJQJU^JmHnHuhKCJOJQJ^Jh'hqCJOJQJ^J" jh'hJCJOJQJ^Jh'ha=CJOJQJ^Jh'hJCJOJQJ^Jh'hJOJQJ^Jh'h'OJQJ^J h'hBCJOJQJ^JaJh'hB5OJQJ^JhB5OJQJ^JKKLLLLy|kdR$$Ifl      0=%*%0      P+2 s2 s4 la $Ifgd0XLLLMyy $Ifgd0X|kd$$Ifl      `0=%*%0      P+2 s2 s4 laMMM8N9NNN O!O"OvOwOO}}}}}pphhhhdhgdJ &d P gdJgdJ|kd$$Ifl      0=%*%  0      P+2 s2 s4 la :N;NKN}NNNNNNNNO O!O"OOOP P PPPPPPPPPQլŃviWWWWWW" jh'hJCJOJQJ^Jh'hJOJQJ^Jh'h'OJQJ^Jh'h'>*CJOJQJ^J0jh'hJCJOJQJU^JmHnHu0jh'hJCJOJQJU^JmHnHuh'hJ>*CJOJQJ^Jh'hJCJOJQJ^J6jh'hJ5CJOJQJU\^JmHnHuOOPPPPy|kdX$$Ifl      0=%*%0      P+2 s2 s4 la $Ifgd0XPPPQyy $Ifgd0X|kd$$Ifl      `0=%*%0      P+2 s2 s4 laQQQ8R9RRR S!S"SrSsSS}}}}}pphhhhdhgdJ &d P gdJgdJ|kd$$Ifl      0=%*%  0      P+2 s2 s4 la QQRR9R:R;RKR}RRRRRRRRS S!S"SSSSS⽡xh[N?h'ha=CJOJQJ^Jh'hJOJQJ^Jh'h'OJQJ^Jh'h'>*CJOJQJ^J0jh'hJCJOJQJU^JmHnHuh'hJ>*CJOJQJ^J6jh'hJ5CJOJQJU\^JmHnHu0jh'hJCJOJQJU^JmHnHuhKCJOJQJ^Jh'hJCJOJQJ^Jh'hqCJOJQJ^JSS TTTTy|kd^$$Ifl      0=%*%0      P+2 s2 s4 la $Ifgd0XSSTTTTTTTTTTTUVV5V6V7VGVyVVVVVVVVWWWW߫fYUhGch'hJOJQJ^J0jh'hJCJOJQJU^JmHnHuh'hJ>*CJOJQJ^J6jh'hJ5CJOJQJU\^JmHnHu0jh'hJCJOJQJU^JmHnHuhKCJOJQJ^Jh'hqCJOJQJ^Jh'hJCJOJQJ^J" jh'hJCJOJQJ^JTTTTyy $Ifgd0X|kd$$Ifl      `0=%*%0      P+2 s2 s4 laTTT4V5VVVWWWX}}}}}}up^$|&@#$/Ifgd{gdZdhgdJgdJ|kd$$Ifl      0=%*%  0      P+2 s2 s4 la W>W@WWWXXXpXqXrX|XXXXXXXXXX Y YEYFYGYȸqaSBS h{hGcCJOJQJ^JaJh{hGc>*OJQJ^Jh{hGc5CJOJQJ^Jh{hGc5OJQJ^Jh{hGcCJOJQJ^Jh{ha=OJQJ^Jh{hGcOJQJ^Jh{hGc5OJQJ\^Jh{ha=5OJQJ\^Jh{h15OJQJ\^J&h{h{5CJOJQJ\^JaJ&h{ha=5CJOJQJ\^JaJXXXpXqXrX|X}XXXXvqqeeeee $$Ifa$gdgdGc)$$d%d &d'd NO PQ a$gd1Jkdd$$Ifl+, t 6@|,644 la$$|&@#$/Ifa$gd1 XXXul $Ifgdkd$$Ifl4      nF G" + o  0      ,    4 la|f4XXXX $If^gd h$If^hgdakd$$Ifl4       +, 0      ,4 la|f4XXX Yr $If^gd $Ifgdvkd$$Ifl4      0 +`K0      ,4 la|f4 Y YEYFYakd $$Ifl4       +, 0      ,4 la|f4 $IfgdvkdG$$Ifl4      0 + K0      ,4 la|f4FYGYHYYYYYY $$Ifa$gdakd$$Ifl4       +,0      ,4 la|f4 $IfgdGYHYYYYYYYYZ>@BXŴsgsXF"h{hGc5CJOJQJ\^Jh{h)>CJOJQJ^JhGcCJOJQJ^J h)>h)>CJ OJQJ^JaJ h{hGc5OJQJ\^JU jh{hGcOJQJ^Jh)>CJOJQJ^JaJ h)>h)>CJOJQJ^JaJh)>CJOJQJ^JaJ hahGcCJOJQJ^JaJh{hGcCJOJQJ^Jh{hGcOJQJ^J  I am eligible for Medicare. 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: _________________________________________ _________________________________________ _________________________________________ _________________________________________ ( 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.     PAGE  Model General Notice (abbreviated version) Instructions: To change the benefit option(s) for your COBRA continuation coverage to something different than what you have, complete this Form and return it to us. Under federal law, you have 90 days after the date of this notice to decide whether you want to switch benefit options. Send completed Form to: [Enter Name and Address] This Form must be completed and returned by mail [or describe other means of submission and due date]. If mailed, it must be post-marked no later than [enter date]. @Byyppyd $$Ifa$gd $Ifgd)> $Ifgd|kdA$$Ifl      0D% +4&0      ,2 s2 s4 la|y $Ifgd|kd$$Ifl      0D% +4&  0      ,2 s2 s4 la|JL $Ifgd $$Ifa$gdckd$$Ifl4       +,0      ,4 la|f4bzƷgWWWF h{hGcCJOJQJ^JaJh{hGc>*CJOJQJ^J6jh{hGc5CJOJQJU\^JmHnHu0jh{hGcCJOJQJU^JmHnHuh{hGcCJOJQJ^JhKCJOJQJ^Jh+h)>CJOJQJ^Jh)>CJOJQJ^Jh{hGcOJQJ^J#h{hGc5CJOJQJ^JaJh{hGc5OJQJ^J $IfgdckdN$$Ifl4       +,0      ,4 la|f4@BDFgdM7gdGcckd$$Ifl4      g +,0      ,4 la|f4 2X|(0B bdfhjlnprtvſſׄ}tkh; 5CJ\h; 5CJ\ h; 5\hhI hB*CJaJphh hGchGch0X hJh0X hC!h; hC!hC!h; h; 0Jjh; 0JUjhfUhf h|ThM7hM7 j*hv?hM70JhGcCJOJQJ^JaJ) dfhjlnprtvjlnprgd; gdGcgdJ&`#$hpPdrtvx´hGcCJOJQJ^JaJhh@h; 56CJ\]hh; 5CJ\hpf5CJ\h; 5CJ\h@h; 5CJ\rtvxgdGcgd9 01h/R!:p@D/ =!"#$% = 0&P1h/R!:pD/ =!"#@$@%  0&P+p,p-p.p1h/R!4567:p,/ =!"#@$@% ~&P+p,p-p.p1h/R 4567:pa=/ =!"#$% ~&P+p,p-p.p1h/R 4567:pa=/ =!"#$% neUOQPNG  IHDRj--sRGBPLTE%@cBUqDVrXg~Zhkwlxe>rS{|!"@@evWWzzjj͵ǪǼ×а׻ʤԿ9UIDATx{C<aOQy]W_^۴*[!p.:J˹&υ\C!p\8 !p8.CpC!p\8 !p8.'Ku3!#c뺢H,x09"khN[WD( $&TI#fNĤ!vOSӅD@ WI!#ekf: B9b1aeAI Ӄ`)SbB4%}jab<%ꮵ0rЦ&jb؆T5 595˚ z3 x@gUM$iO-RI`2uHx49 !:jFݒ¼r` EcH^3OeC$F|6ae a] ؊@'oBppSS-<GOFLevƬƆ`AnKś%TǍB(3'i RuJA:6ޗ7Q`QLSQ;IC ʐ\ TQx#X2HPN,ð k`fY7FE#vJMB,V7C.Bs*AR`(@sZ^WW.F` eBUHp0BpTWERlU@!Z6@HBeJ"aJiZ@JDpkzdmH("# F&Ad.xc5CHS #dWFE#'C& !TK| )3*C@! ~6k6,pZKЧx#$YSGytGb }X)TiiD a6-$l!|:3DUY'Q_7w$dQgc%? Ajd$ɭ53v%hF.Fs%9y2`hyj># expQr,mBj!]?x <.K6~$vو &*;\$OfS=*a D7+\:.^J^x)H*U/!3K HIjf,i٬ 8@H0 N#QU0 RF%C -MHP0XAHϐ׊]lܯ9ڻ'/Z/}߅= [WvW<75|pѫh R"6iǪ|!*~q':H^Q_{mxk—?џ.?Og!6DPT< թNhMZ=Ya/Pu/īU8{ ._py{}~ (W;B ZOjNY*+N7+hL 2n0W|j3;{Iً'/}vBf5$M6 9R EBl,R}(BW?BڼUIv˝X:T0hؐKh~]P &R`M_j g_sazG>4݇ᑠZ^?i` O(.gYnTˡ{y\.ޑ &&9zcPI#V+o2IVB?s'(RXTᇿ88hrˣA:sh]5{#,*@];)ܝ^ %@P c0 KW(COd8qG= xgkXIjy#OK5LBuE=!Qi0v>E_zA@!82T},P=ͅL5(oz0 sE98Xy؋L$&vGs;Afz{70"gĄa{jA^%G-g4ӣGAWح0&.ѫ<9'PVҶ S.[E=i[\Fv"<9[?~1.|#AU \)ڠ?P2 y!8O0/# Z/L}v~V?ZkX@;Az67DyvuQCu7*03GAM Tsf2InbZZ9oQ{, H$m UcgTQRG)O ɟxK|YT! Hf5>ux+_!<%!#V1> 9v!@V(&' ᳞!O–`ބ!b!')r4gC8C8I m/I'y(ޅg_g, GxQt'$eWu67doopm27 {U> z%i SvB)|3#{_<)C #qF-RRݜ[>! #]!, ?8^'LH @ fH ;Ah aϧ7!<-: @G8E߷H#EXc58$@Pk #8[>;@;Bx$[yY3kB p$A38~#VAw4˄>r c?ʋ~},A͸^_$F!$ 7}X ͽNZmI߮! 7Q}Cûgו3 "wtndq6Z"vL@ CHLi9T(Pؠ >ȿEryMR! N"~i^(iF J 1+.ЀѨ@- }j 9QbB۽aoO|[ "[\ ci )1dSbӂ>]e=S &AҶm0AɎD*E%k,ۨ-!v]!7ZBnX@:ˬ/?6; PdJa R[¢ s;_c BRYjc^o)7m[ٝw!(х`B1[?!}އpmpgu@At $Yjmln d9&^Y f!F; >:ҔYLUҊ-~|yqeb % Q%),VE͌ B#ԕ'CCH 6pKkg2y~V!PQD4k~ xZ¼͖eO倆@ BJi1wBU=IT(Ra8/6΋)S%3$@Bj Ĺ'vlCrz/0=ּKFBj ؛gIm9N[o3)@H撣Da˶7,:E,mv`P,iCH=uH97*mkaI ZbOͮ~Ҝ=;ʦ A>BJv{:BgMQ BuEwONHNfo.9y>.ҨlYBt4jhaZuQNOCHcsyj [^ 8Cڐ&,t~~v32 CHsC zVg^&pHg$Nr% tR5!}C*g7-TJ*ӛu]9rART)(2 >y'ʃ8! 6H/pDqI0ug4RSS6OL"m/vY6}CHKJXh_vBQABCm8"G·cJm 4O|Qs|3Wqyvp}L@qᴎ!d5P`k < ᠳQAȂX5+2P-H{,!vd [ !xg!\O(^1[1_SY@V^[1X v3ŰRտ_Oq\p2,XQ3 0BȢ)R?3B>,fI@~@1U ` p<8!@,:v r @tY .y1! G fC7GZ6i`0C46%жz N x; ɂ6 &{ ~xC]3%nKd,g}^[Gc ?fc@!(茧1!3> ;& 7D2?fZ;!,M;GÁ;VFPHr@;^<"ָJ.n9ٶ0zŖq+4$E#6yy4' )ȁyG[|^ a!?Zx/7'=!j؋]DPςp"{`)Aw}״.% 3`!02Aa87DrTdwTx<DA!O7ϋI+>a;\ߖD? V`ńbx^,.NNNn&=~;;;[.w!e|u(cʚƫTT !( aeFZ2#`@4"hC{%Q.k LB01%49LD 8isت0=P [2)ۃ'H$LK4VSٳxºA*JTچ\'4IA}FenC̃9?4QLID[]$N& !r[N{rl]U _|u"w($8STҡ-VQhk)!a}Jk B(I3'BdAӞ-` XA%a: !eA(b%UUmg+fC(}J|>pC!p\8 !p8.CpC!p\8 !p8.CpC!p\8 !p8.CpC!p\8} ?IENDB`Fpa($/V='I@JFIF``JFIF``JFIF``ExifII*C    $.' ",#(7),01444'9=82<.342C  2!!22222222222222222222222222222222222222222222222222" }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ?( ( ( ( ( ( ( ( ( ( ( ( ( *jvITgo JhY7?%?Ƒumլo}y **(`LRu(⥠((((((((((((((((((((() OPvtk@}'ڹO%M?D7e1Ztk9|۩Zz=̅,uhhw HPMK3]28s6HՋs-Dkom_q=^5z nk6 4Ni#>ǚР((((((((((((((((H፤FYk UMolNEl$gA^w3M^,";!>'5ĪɥCq\ uϔXTz~y>Ŷy ׹)}Iջ|2ӭoQFu䣷gҀ1$񞭯ghSlkszƿ;:،й4 nj,*-lhwI9O Œ yt|9 Wf|^)3Y'e › zg8jEHTTFڀ<ź d$#Â@-qPXi1v[ܠ8WbT{ߎmogsmk^Dr ,6qܝ{q@,ukjnF/1?)_C't'o,%7PD| z5W7owm摥{K#˝͎znV7hqr}Oki 2Rh2?p}r=klkH7n Kid+w~%諭xFO+han PQhseu-fVF 9L; Gns-g_-%3,L ,zzx.]hKPSr9׮Giǎ|Ɵ]xϋњLJk z]i4&"l>Jϱ 0G=s Z:|#xy$k;1% \R@>U+[;[(|Hc-ŊġFI8+RӴ-o7Y7ž+fYRQiAKx/5}FIF嵶 cr4fu05uQXzP =Y8V65KVn+ȹnV9~ 55& u9y-G}'z'wd|ِ9FiMaEn!})$cLhn)7-c k|U[+]F++-& =TQEQEQEQEQEQEQEQEQEQEQEQEQEckZu p[ܟ_'y}malSQVo_@;apzgHynM7#aϩ\lv{-{XE<:Σ)ۓkdݽ=]&iZKY^ߛdbhX@2xPwRi.ež{zq.-dY"{weqW[ȊIR?FvPɂRђN7GHr ?1G#6)7^` ^Ko&{5x'P7tdHO$:?V*OfO X[OF}v(Fw?k%q}Asem4ʔ<+0e#$ts©}owwC; Oz>v+iz%2:[H\磜3@?-n/Sk ǃH<|Z~˨P ,Fp AǮGj> N!P-`^vs~e6WwGAcy _$X,u iA)i"B@% i7SxACjqE?@P:}9Z6C}pJzb~2y+5\Zx\q*Xi&scl@~)։eZ7Mb;s(b %%l_W4f-GRS#~{KX7MB|َo ЬZVo%O*sYP=A?mj2m$][w*aGV7rv=p]vھfe#qcx9r~?+f|1+k#?yV6O:,A_mZ^6m#'4CD֟VD{ cŰZWm>>_{3sO<+#Bii\OAz}s5>ssOC$se.΄3pzt9@߃| wևaNf[g§!nt;c1>yCx5hm.+H1 Dʋ$n zPKoߢ;>ٺ|܎+Ѽ+?Ĥ:5[}#溗o4K<*NZM5o_,=1SMD`%jA0T^q&Lm ;#{x>@Q@Q@Q@Q@Q@Q@Q@Q@Q@Q@W7ZɕJ սxWO-gg[9`p|5':RJD=͉%?3QzO,[5=%ߓ޴|% FͩܪH1ڎԀgwWZ+R#4z{z\mMDjGvǥp:5_PF .~rvGVc*2={{{{U [[.Gv9ڀ07_xKUIgv2@؀gT}sO>i'եUs؁@yI|G%ʑXp?ʈlc޲jJ=RXUt ~ȼ*?/.  \D24UhV 'f߉qmA:.?,ֺi+Tb-xemCr0FT?B?T("f\$ nгYϪ_&#r]k?OG:q܋-@eЋ1SIkIϹ&ILy3N)Yy'/&_QWV`?"q^NRQ)*GB '}'==qO]#qĦ9O> \K3^ <X ?J]=B*{V]xQc!ڔ~VjܸyrTקQ&z uRv/q g .KZZur[OպA/[5x' Ⱦ?+? 6[idλˌp8:W.u[CiY܌\ĸAq_j!!8DQtvf*C HǷO\WO3;ڀ#Ѽ]$S}T$t#߭h¶[iw}]ߏ$+i<h%mcǡr{OStM"L[g+3olN8up޴'Sj]cJ:nRG?Gߠo< 4z^$^cu{_qW]lu! 4S!S92&h$ "HApnȥhX]C+`z{GAÛy.-;|2bOp?꽺⽢⺂9dE!pEMEPEPEPEPEPEPEPEPE+YnU]K?}(O  "כO̫_ʹB#yϰ5+2Y¶6m6'^*ߋJ4{c-38?3h: >bs$E#{AYmؑ^*/u![VYmYJav29wsRY_VO0ҮxŶ|yQ뎿vmIkp8<#{0})?v }˕$ϰ4WGFµܛ ( )qF*$QKQK{9ĢbIĢ-5\Z>y6=vf.[.'WErѫDjMoxkqV;PF>LִюFDw9 ~5t}=#x؜pE>i۴3dHJe<د0i( .鬵0>Ib;X{Oar 1 qgy-4 w2[6 rĪ_{~}J:ԑ;?eenX>$WcPBEty!#>~ִHʺI,fX?62sR(!8P0{cE"U'o:bV2W3\YzgX=[?0eᑻ2#֖WuW?гM[{{c|RO7uC&~tFdaۨ/ir-orbzH?E'= hI &/DH =\ŰW Tk_Idk/ǮG߁A'{R_뒳FN49? =GF+((((((((}W/(Գ=IzYkGq"$nDqOW䉿~ql yMN֑랟a]owXI BTcZ%F*  E? +ܿi"Za̐FZ! }:tE"orQ V |1H+XxT\0kDQ᧝;~ Ф#)NEQ& J\R4(I-QE0 ( ( ( ()QP;Y8V7ZmSzieZfk) A 44{ƣಡD>R[OUgCjN 6+[N=C^Wn˧j́Wok<5tu#M݀2>5^Kh4lj3\ޘ-| OxRoZGRŰPz_4gcA GB;F h:Go?d0'Ԝ>l0;V#=;P[okV (G/0x}uC}lKϏ㪷CºǸ5xD` R6199?"/􇴺Gk xSw cף9#dӵB\ӈKy2v ZL$Ӑ._k/v^LV>5Ņ݇XxC~G>4=b:5ɾ=Tr@Q@Q@Q@Q@Q@s+՟N'V)f ($!曭jCdUl ; _KmIKC I~ֻ6Kxyx3Ò{oᾐڍϋ/V# S/-+"_/תOcs^a6jzDpX’FKH4+Q5 "`=:};~]1DJ#X8'ld."K$dWWy?~;Hck}sH3V] 5~'z$7卬#]@RI*O= ?=+r3ПW~*Yh求_2qNrZfg'.!$B`C&W#'WԯRk+i v0w pX!gmkPVgeyC{zu=񏉡ҬWLӂB:~9Tw`݊1Zº~*GMzzƼYdVW.rzDI4,]&Ҿ ۯVa)\(wD-I-;뗞] {Y" @.㿯ZYZ7(`_D|'hk5vlE/*q: 'Gcþ'ksx8r~Y>~oPÚ1IW٭睊EJ.gКL*߅"w#??*9c^q⟄qu[\ȣ+¾/?g_K_c}8E;5`!(ףx[մ<|2/oz- ;-^܈<~0p=3]ץ㆜>v)&"IUAu}£Zv]BIi89#q~|7gѴta$ >31\\_0N`\nq}1Ca 4zգ96x))ԄW蓅GĮ5LK 2HA'pW# IRo AGڭb+WYs9fWA [~uEy/|_iF6$Q<]Ğ֍}pϒ~Ndñt}HH+͠} zWYǩEn nad.Y[?"GȖd"b@9PxK[4ŜQ1ڟ?H+uMQVf>%'-܏\ߓ@>V+>lB̧>=Gj6j]-%^vG(j<m5+88\*}״4,قL1$.AOӱ]Y7܇/V}1C޽|>'+#Cْ3G"gUys Auq-^*?Fo((((([84_yXW_J_7Ciu.ߎ_MGZ"Ĺ;>ifdEmچ z,?zuN b8v!$j?Ux\կmHIU$4qn`ǃqso:dyvRxSNNOt$Q q"ݱ :t8=;\Z>d2r^ոvpNMMxKծHmw+Ook}jPY䱈7 lpjC$7S,K-G`OAzN|F%g|Eo1%dz4DKh|<Fggn5iu1Fe8yV? +d\1ðq^5uu-3e{j&I&bV;} aXvÞ_ g+xB<́($(`zM׮4׽xb3$q0 suLv ~Iǹ w[MnGC~j[ٯ-ށJ29&t}z-rɮ= -KǗ, EUL}:枰lCc}?WvHMdeܙgR,*J |_5?~ cp=7[YJ]To ߹1aNǓ}*ɣ nDDG$`HPGzƔ Z #G^r>~W[Vp2H:b=+Zqvfj~+ͬyH@$c'?ʸoh?ZyZ?3u5(<9e\nq$>Î߃m6ٓg0 ( ( ( |c)sx: f+:}=߸-9IB(̼k<גxvljn]mCcq v fO­e›$$g95x*ٵ_jæOO:N}#kZKXebR3R{ -)Uc;vil3;I2>^jvZMmy? s2su 򰎣}/ ̠`OTtr[A1>: n_?1A;ʽ j=vEZ(+QEt%ea EU(Z<#j:nmoe(fTnA8>h\f4;y.p>dO/Q20&+}jm*mWf׎2ekbV,r $ˏ;t_0R39z~ LU]ZE5xnowׁ'iHd;:pI(J,3!r?E25Ͷ?8F!s}ߞ~>o?pJy'~;熆e/&;B 'm~񑎣zW< D]f]Q= ʾVD$QxWpO m*ΤGm9+kKxCSѼZkp9THK7zNx'=6"#w5\~Ƈs&n"4>lu<1]/Wjd܀P^}jTW4#%fkt՛ϛCky",q+l,h_[Z;V.IR2 }aܧG5kFmLr>)8(\ǿoa|m1ڢY(t+;2?ϵ>V]ff }o K ћ]G$-X@bTz*u:K 0Ky`,xsڼc◎u8;]71"Al}8׷eؘӧvv^oIFukPu)Mi63GO53(waaPVK)9;($(@4N"\Ga xi`-NӞ?Oz?Ez7S+ eV?qp}ڼLH ڽI^{i»P1~^;=M`Gx=zT} CYh<[;f_.ù8< _c}&omcԐ>Y?^o E6{l[Cg;Whzq:X(m촩܆u(}:g áGn1ݷ\mSk=9iHWԟ_EyW baü-#Lq8fՓ$ǚ?PW[ /š%{hWY$=H8'$>-i9'~Ʌ}w}r1@ O"j~m!Ό|ݯj[rMs-;~eϺ? 8.<ƲF+ EPEPEP)f ($ ׵p4ZRw_<UUz o6$ jX&G O^!vV+e㑼 > '..N޻ XF9ﯵ)$u?-Lgi#r9ŷp>1+yq@?b DX'4,H`(oxm`ctnߘ9 _RBM%հ2;#c;ik9vi"'FwLkWKDݴ7y _<7ZO1wn |Ϩ5g3ZDHO-"?V'hu{O%=POJsvkZa٣[W@aB pAיV/q!m~&k>ʊ0 Q@NzŠ(QEQEQE//ƛ : MCOK2@㯾^Tsފ< ×n}ƴJ>Ljts`Ѵ嬋A;2ϵSn\p;pk#ѥl"Xy:?ZdxdbnAsҿŪp8VIoS4jR/%\pB6 4[MB^y8 ?_^d %H9G}`&Xl|Ij859Bڌiu -5 KXPHFs}(˾[Tߙ'۵jQ^}_}u{4ڿ-~3ʓZ&[TӭpFйTvcڪ"ͪ@3fWevϵh[[ D&f1催kcq5V>Pdݓ!(OUGlpF~e8\6ny5*Joch Š((u!Q5t1;aYgDW_!}!I8t`ןҔ_R-u;m5u[=-Eu^']i.gCmVT%#9r:\F[Z]g'D!di*#Erf.&kKK($1I$Nz:⫶i1K$Җ=Ѷ{ֳ⑭ʬJ02x𥄒$~DCi |3\Aw9W]Kx,I1Jt'We1}Iw4v-j_W+D?/ʤ~kl=?iV1ݑI$y$8-WJVVQEP((((п 5wm4{p\2t##hkHwu둃_98^LouK~U o '9lGqV]KsjN}0Xy%Sx'm4Ӭd2N#@k9?{Rxgjͫk--2, S0yyuzEo-O9B {}]qyeׄ+\#H g,)?iAQΡn}V{0eb?AZ6ԃILhGcg%ĊX.U'|\ΩCK;ZZP1+[DZ@kVޜ/-T c6Ѹ>נ_^jIy'W|CAHL?]-{Ծgfzgb@;ׄxf_f}eQ~Ǡu+bB(B(((((ŸO `-&l`qb;WGָq~K"/GиNPw7p^"6 s ,fI&e.*fpPW$5.,7(9vؚ+hccr GtۋWN H6O} d<Ҍfԣ%fg.IrYVK,j>h? Bp9~OЏ**3^wggЍ{B䟑MIJ+)FLZ( ( ( ( ( ()pGK>%+ោ,I3><(O'=cIj[*#8==6zΉ Y|9n%UExɤS1#GdԵ+it]:8H˜Zqxx@m6 ]n* ''# kìAAY\|Yr>>$hZ[4 ,7b_?w=+d毉um5vtR原}XZ%e>a<a֝14zLTc)xci>+xjԷ{cu8h<}'R/@O۱zqx\}wmΕ-?~M&Aw gs0$^_S@JtyeQ<ڬ{Tes{3:|@д}>[}6hucn<=1XfT&W Y7ĞJp9Fj+a۾rZ& <;x+o##ݼ6z*}?ɽ/ ZH E~F.;9(AEPEPEPMSksZI]l$9WW$8^_3YL12ZTǭE4YY瀬s 3(h_ @^:7--*v|'<:my"-x6Xz[f 7W&Ffmn~ wbEnGhOZ+[uX O8:;pzyWOu U(k,@] }ME|٭;] }'~Z,]MdnW_GtP| !+wtY2209hr=I qު˩H=P*Y\8RGO<'Ϯhbci",`|vI0Tg {­q^jwcgy1/=V7瑏$/ Gs?c(3FzRR}%?ɋEWA!EPEPEPgOjuQ^EO'3~rּҽ} ZxWTF\V[fRsI3? ?z! W/6uC3? ?_n:4Ƅ+ǿҹin[@?.9j:V5S'W?BxcY,lb"X_z#_G >xiTuǃ U:Uz>>?v?c1~_?6}W?Ef{Wo8Pt†5eKxa2?||뷯\V1CmrPcE?_nC4W#lӥy~caQcE_nCAsp L,~褸6nʻvH_^nj.)'V6Vc\ϵw??j?vZ+TwIDySi EWfQEQEݩ^B׬HWmks[+m5m1_??r+֙~CBlv~VH;8Tl(늊V>!oק^Eqw9w k'liX?ΰwtFֻg$G<XI 6k,VoLvNJ1)?2-h}mx{oCڵ\]"ґN0Ej{IGUaHR QRTxX#g!UQoLihi-TX<s1t"FNؽi,Ii ;~==X4#r9?WNk85c { $#Yt/"m-|{S[b_\kGBhe$x|ڶnw74Ɏ 7ڳCW#V'2;ZЮdҢV- %Y|Ү+;Y+.\ _e76qqX(szטSuZ{WuJn\k\/j[C+<(d(()қXzh|hdpX+|z/ X#ܕכzOӯ۟^e?בH꫗oY8Dzͩz-툻&F =gi? ^Si*GyQ=^uwogs2Dgls5B wH$,1 @Why΋Zi }i^]^6H܃;]_t> X]3,{$#j~V}1o#=ψ]-YXT`cJ77q\=mp6 \:9?zև1m4f3ghF=owb/L}BMCYZZ~Y᷇ R=o٫((+-#]H"e,{\ù>ϬLc$=Xj+jdu0ϰ,D8$ɅomFl/͝s"{Aֱ!}J#[aʻ>2(*;Qquohe~T:su}r{"@MҼ7&a= `m4IL*Otzj>;l򉝇_W/s,Of$(:|= w7aGxg;+>(+_Fd%kmմkG #d;\ty1^u} ߀H 2*Gq[a{:f&4H 8 qP(5ԝ (Q@Q@ }+ھ<ZZ {sgc1D$3^a˪RvݗPu1}SwW*OOm[x6y缑~Oc$1_V=>N&=v{hbBʡ97VVk7w6Mmz# AG)2DK&XShү?';oе;yj?tGw?x$z i?"5TZ^wrLEr(~'O$z jK}kwS64pČO  uLjW4{WveTVzz*um6$/lS-ӼdzW//,~n!KL푚ʞQR&]lfTʕTgo=3kc3G&מI5 ]G$znT~&"IY1=Mxo$zn=kֿU?dT_~&j$8Zڴ닋jYyYW/+ck2^ɩ:XTD܏SthJ(S((CIJzW4R;oF&c>?vk|Vv|_O ^rr|p?Z~ZƲyq8sK~U9Oi^Mt7Zi\M*vQZ~U$wNo5`2gcH; 2ygOŶeڮ#Ԍ3]e+5㌀yQ(z2䌂25vڌ׮$ V !g=ppF]$J^G 1yUԼQ2D OݞAolԚ>$di HQGrXufY uڿ9>P?.`:ſiz.{B熠,R>R%(Uf(((dn}*xu[ospkȼc7N(ŬLG\ ߕ} <$ xR)"M5𦡢i$bÒJFMn tuH׶`ヌ~ֹm'š׉T@걏6VS,N]> 5I1 r|g75_x{JQ Qe(T}?Z5Лwstc GIuZ-c#d==N?UHlټ˻?_O} L-RM#HG)M7#Ձ,QRd[ޯݐGI h[Qxl]2AGBX^lȗ-x_B x_uYv>%QZëחha5f(ӫԦ (AEPEP_!]5O^~g??:x3vH hd>#$Wewk4LsYg^ElukY{yuTq߇_½P6Z6Sԯ5r*C%>? 7U[m-W=O&{ɦqDpD aF20Oݒiy]룦2ՖaQ(mip?#nVn#O!) vUdR[~Njr[~%yV(cy$cDRI>WUa{\KR7}liS6?cFrUGOlUE'/S٭O.kn/WFeC7IY L1RxJ{? k]w2];KxtO|ðQ 8 炙cZ?ּ.*5-գlCeĹv敹gsޟ^=ڬjRG% X$ nxwS5;w0Uwr7Mҽ|BhN-[-SM_[iM. gEr*\֝9H%^]}$<p8}1\4GX< hgeFc09g$^9Ե]xxLާ:KYNJO&Ugh9Pᑆ5Bz7-.ۣWAdT~Cf_=XQEw!EPE4VW-\GKI*sQwᮌۦ\f7sҼMeJbxLJ|m[!ªcsWoڧol6KbO\UO*1iRgW?5v4o4hҠHdxOA_Vu%seS)HHWduODᶒ2ru#ҦFin-5 }$*|ChR$7k=8^FviwN"M3V_ܑUZKaRkU`NG,p[}u=ȵ >ܫ 귚ցoD4*@HSU ]Kc'=X_ _WjaO̕oPXt{l fm\I~~:ɶVN PQEQEQEWi_Bնm_kի5s/c䪂=TPx6_jXnPg~WԐTxAoclɁ$瞝ON1Yd`Ęï⤏W Nvr?qV !_XnoP~?ȮK4:b~rǯzab8_XӈZ_àh{ė6dqQY1Ӧ\)Vxz9Eha1yWCWGxӭ^X׷lV3<]w-um'Wtۻ6[Ba:v`m9eM|5|w1Ef23^7XɦZH1{/{ _[ao/$OҸš՚rpr?ֽWGҊJ+S(k;QE0 (54ĿXkWyI쵘mgUH  ڼqRSgc);-&UH'ii!մ;cܧ=&# ;/գ#R5-_hu_G+[j 4#sc)yyN]$YTtRiWf `TllV8`"叫s\{'>YD?*<]|'v̬ux3~?•|O E"<mKT½WV_٘$?x/j>yMN߽W EthkL?]Go]ԥBks_LWFvâ0u9nj8F6d~?ךoW/t?1i|a@W,_G Gixd_I(I܇_=EyVw7muo$hgW/nAR¶hlUuPxz 5.6USNͣ"AkxOa0ΊqY= ~IK .[]+8(JM%sWe! I'vl\NY~5|;uf6dx˭u7Q7i:u'?=\O4znk>imj]VR<| Edj>25W+HFնIHZem{[<~x"HtW;<1x0Cf>H]?NԮ) yav}jPVmywsk3@܎q}4Q1-q` _\gk-t|˩BQ7^}/~VJ|!Z.EOXHڇƏus];$Ix=ɫ}u hmˁsw g+EI)Cvw&'蕳լGT:OfuXۓ}+]lK4v`#޹sOkkvY?u~v^ܮ-:Sk(ŬjʸfR:ը'[j[39#A.Ȯ U!<=e#Jœe 2Eb) Tam?8"IE܎=Tx-r'=hbmvPQM̠W=*;|XxZi6 6|Jn\k\7j~0L?-k_М?"_ؔQE{&aA4VSCAW4MB +e-,`gU@ $R_kE6qk_l<sӞm"!o*r6CH'[a ^oL[=1. Jn'ԟjƑ6t?d9^Hϸҹ+³IK 0~B sq@_gkɜ㧹.4 Ġ(9bx{ [mˁ NI.9Z4:DΛ`E=_dz@O%"ˢ{>v=s]PEPEPEPEP6Zkqte#5ٍcux;QboNLv1j:$hXiU\ H/o_/a{}NOҵ|/ɥxnx"tR]"I<ymIk->A×&B/ ,< ,C~idc}Itμn>8e}>b qqw_ּ}KMTIFdПCnh֣}XPZᑺ*Lg9w$$\V#<^)S`fe]f<.=9=zֶ跶fg5"8໋-:9yΟ1'>W垟,w %hPdǿ`F{W^ܭH8,ǀ>\)eK7w\r>u=B7]ki?$X}>&9k hHL)Ǡǁ <)'|(^j$`~Aؖ6f/ҖtyDq z((((((wK 3$:1Jyh凶Gx+e%: ,o)7=5zgMKʙxuѸ]Ob, W<,v۶(TBK3vd,t{%8Gz}::5x[Y3ħr-OvQ}k#žJI'=}H\G5)i @)}} wO.Y-;ɮBҬ4匸|> ;1x2U!l$?zO迉Z!IeO9|:ÂQ]휭sdt-b>exvX'VY+q\Nu[I-g;}?4i^ MWA{u6s}:cxv^&}Ǯ8>xf;hBWuO h/xj=䖸G#?]:VJ pA+loؖR.A=7pF2+̵ j:nb-i@}1[FzK2,b5& Zgys^yi3q D8*ETn5#5<kIסV=;SS)[UL`rA_EĞ v:B ~yj/ouZGtWiuXUWR-nՠ]º~ ]5u_<փ֓kɧjtSҥLIWSu?ϥD'xH[\įߐb퐑}cWEej14ksבSZr^܈Ss$6 #?Ұ%I\W`b Zyq}9;UGIxSJ(0{՛.S} ]7$jnGvg>jjaO+5©k>7`u׮ӧJO7b;1c$SMW-ݷc!XҹC㎵6WJ|8z~)6e=)O30K+U=kok.{6i*Oo*IxMst?E_]pm:Urkd8eQZ:  ;+-X$;ս7Lծŵ 4R{W!nq}T0@}\u: TbٕOQ$G~ڴMCڠ؋>m%:\6#AkM&6+%?ݏی[i XLv{w'}? ^|f$M XgLvwp~gX!5{iֲcv#=+vnB2Oa5i2/~d?u> ]FhGsp[ps#N>&_a~ b)h?:xŨỶ8Y`zr ּ6-]KJĚtIO1dd2k(ljaxΚX;/O>3eR3;@A՜8cs|6k)wc4]=I=vejgr8'?ڼ:Υg=W.!E;>yɭOk鳼n >oκLoPcX_ÛhEc`uvͧ<5kYKd  [Q@Q@Q@Q@Q@Q@Q@q;Wv k69{YOS{\4Pҿ?+*" A,5Uu8m,,:?ox2]x~#>>؀ch1x gHr28<^@j߆nEV n}1><)ɦך4Ny,@1Scp ыmNgm랪0x>>'յ:{ye_nW=_[%I&H_?}ᇼ?GenGizzz$zwɝ.M<8;&eDgf $ w97q5'X>MQ]_EQJ T t#90 ]ʭKu"2oƻ_MxSMvuaʳ~ ^!t:4(AKE"֚CxC;𒑔[+Ю,=ĭq=j${Y}nǾ#9'~G2= u?7A~?˫;70N8^u-o\96W_eslzm7[%4sU?^2Kݞ!3iF+u4[$gFlGҸ]CEԴ+yi,xE{T1j/^ţ>4WjmlH4U{IK4N6du2QS'|H8otӅ{ BqYZEݮu)bv9%~&:כκ'g}?3$IM(D&i(U[+DVLi|2.˩GeR ~+b[8dGFN?wo{|WoZcvF]khfvb= E ~+)sMV=x؜siE:[Ek|瑳uoJIF9|T ;NWa?J9+gυZ!ϧG󮢼wf8ަ  ⳼Eb7ad18f?W"x ico4 d+4 !sWP7-@F@ `Vkriv]ޱ!y{??\⻵xo"Y~y8—>~zh>^0G?=<dqeIldIj!4$dvc=:/|S\4YNpÑ{tϠ"4Jkf&:=C(AXúԌv9ʯmmVѤPD#T X((((((((ƾ 8G/\}TI{`:AxV:E"bA?8Z񟀮ȑ9sd0uܰ$<Ű:ų~X\pG#>xeD僝n2F7z?\ԿӵCH>sOJICsEs}:ރ2炯ooԼA $<9 Yi1=V!^I\M7 &] `= ĿhdWa;ȲOЃWM,]j_ S<^"l|:MV2B|[V 𦐬׳U&WOxR0l'*Ӱ?*ӵ]++jWJ1Tϲ?qWRF xKŎ`$X>W4O17̗ю]Uޭ@`܁aMG|@5JqHu\s\Dz_=_/[Ad{czUk?شyn|c.{(\})5X}RQkR ,オs?^j5wD|@d+oZK_dyY_}q2z8S{a{e CA\' S80>ڻ0@p?jg` 1P~SW >H4Ų*.ݨ v'}Y.mYG@׭,5HoC^q"ck=>U#hΓnx%Eb@)unpʑw#Mz.)qfAKcV5 z8cm xLbM#@c\#oS,Q4+VtӥvVW]\G<}׌ϸ?Ek955s2G4W >V3jHlBj[i ,o}kNԣNl1xlր5__M7MqF\}ҹ^>8.VerBL8y+<WjbBN?+WBfCf<AytNsV[vy$_ =[Z.]Xn @ҽMut ebPNOWZ6ike2 y)̐8>{+xaS_ 4Ge2 HS}Je'=$֬~:ˬs$;vœ:+{t UD\u }O5+GuMj[HnR5Ĩi;ZU!Q(Rm8$QIxvE*X~DW)h.IeƫU}l5:Fk4P7.͂sG}ᨛ1=[hifT1cns|}Wšm/41LW${GOxMtB"u^ܞeXYV^YD?, fU۲6 JXmb>}HH So4~Xi[Euo)P:2dJS6Zuѡa?  7z&lncR)<(}W5fѮAc%G΀?P/.U^52 x+㼃HQ$HfC0'0|Y6XiķTg;@z=gxդ$WOo ooE j#ETTPEPEPEPEPEPEPEPEPEPEPEPEPLeY(ea"EyC;jM6;yS~/q:<_5 :8R8qW5fc ݳuIW8>s@5kDwiß>Z%5fM; E+!c1]i~[=Bye浓d}v~ΨնIuϿA@!eb< ]w4mP *}'ō 76Ąx&\>9p3Ҷyr|Dm尳\Dc 󌑓sƓh%Qg7\LeU_ ck*֚"+X bYšAk2,yi_WPYd=~sydZȲfTn z]JѣHD@xNsZ?ȣ:Uh~/ 1=+ (sRkmh.ojFzW@(ukY]ktܒctZ# ,f sQnT @<T|B#i|1ϥC=~}C6@ eOsk0Dwz׉fL+ǝ8ǧLD~)h$eB`3K *9DsIWk:5#,kcHѵQ@z| 'JResw$G{m?Ͻ\м)l @Ayd#vsWZGzHA+|aleԝ]y\hg6xQ,>}fE?}h=Sv6c#Jz 犱|:O }Klb/z}1,~z_xwOhQ<%'۲>i@֑}5lt{aYϫ1ֶ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( :~fzݹ^zzEynvfq[NL}N W9w<6qm}jnl3:ܐp>khc%M"Xnr|}0-aU:O qת^khNG~u}[tǨ2=w6:g6~fZ}FĞ@՛ns&W~+C!gM0#%\(&2G@OsY|$7$׭_=im}|NJ$ t oh F/2 Fǔb}mlA6{P G\;ҞFqv,>Jň}-+G̣ok)7 @4Ư~}mc1%8)kilAsh>'@Nmn>֙&w.~ˣLu*9n8q^ԓG;?u}Uؼ7;Zg[鱷F~+HEl3qZؠ= @[?AX:X-y"ɻwO/zӬ ~:t"3H?u?ohfc3s<!#5h{xJĿHҷ߄^'O]mt%#xWEpƱĊ 0%r ^y1O((((((((((((((((((((((91HX^ ?i)=2http://www.doleta.gov/tradeact#DyK (www.cms.hhs.gov/COBRAContinuationofCov/yK ^http://www.cms.hhs.gov/COBRAContinuationofCov/DyK www.dol.gov/COBRAyK 2http://www.dol.gov/COBRA$$If|!vh5 5o5#v #vo#v:V l4q0      ,5 5o5/ /  / /  4a|f4$$If|!vh5,#v,:V l40      ,5,/  /  4a|f4$$If|!vh55K#v#vK:V l40      ,+55K/ / 4a|f4$$If|!vh55K#v#vK:V l40      ,+55K/ / 4a|f4$$If|!vh5,#v,:V l40      ,5,/  /  4a|f4$$If|!vh54&5#v4&#v:V l0      ,54&52 s2 s4a|$$If|!vh54&5#v4&#v:V l0      ,54&52 s2 s4a|$$If|!vh54&5#v4&#v:V l0      ,54&52 s2 s4a|$$If|!vh54&5#v4&#v:V l`0      ,54&52 s2 s4a|$$If|!vh54&5#v4&#v:V l0      ,54&5/  2 s2 s4a|$$If|!vh5,#v,:V l4&0      ,5,/ 4a|f4$$If|!vh5,#v,:V l40      ,5,/ 4a|f4$$If|!vh5,#v,:V l4g0      ,5,/  / 4a|f4$$If|!vh5,#v,:V l4a  0      ,5,/  / 4a|f4p $$If|!vh5l*5#vl*#v:V l 0      ,,5l*5/  / 2 s2 s4a|p$$If|!vh5l*5#vl*#v:V l{ 0      ,,5l*5/ /  2 s2 s4a|p$$If|!vh5l*5#vl*#v:V l 0      ,,5l*5/ /  2 s2 s4a|p$$If|!vh5l*5#vl*#v:V lT 0      ,5l*5/ / 2 s2 s4a|p$$If|!vh5,#v,:V l4&  0      ,5,/ /  4a|f4p $$If|!vh5,#v,:V l4&  0      ,5,/ / 4a|f4p $$If!vh5%5#v%#v:V l0      P+5%52 s2 s4$$If!vh5%5#v%#v:V l`0      P+5%52 s2 s4$$If!vh5%5#v%#v:V l0      P+5%5/  2 s2 s4$$If!vh5%5#v%#v:V l0      P+5%52 s2 s4$$If!vh5%5#v%#v:V l`0      P+5%52 s2 s4$$If!vh5%5#v%#v:V l0      P+5%5/  2 s2 s4$$If!vh5%5#v%#v:V l0      P+5%52 s2 s4$$If!vh5%5#v%#v:V l`0      P+5%52 s2 s4$$If!vh5%5#v%#v:V l0      P+5%5/  2 s2 s4$$If!vh5,#v,:Vl t 6@|0,65,$$If|!vh5 5o5#v #vo#v:V l4n0      ,5 5o5/ /  / /  4a|f4$$If|!vh5,#v,:V l40      ,5,/  /  4a|f4$$If|!vh55K#v#vK:V l40      ,+55K/ / 4a|f4$$If|!vh55K#v#vK:V l40      ,+55K/ / 4a|f4$$If|!vh5,#v,:V l40      ,5,/  /  4a|f4$$If|!vh5,#v,:V l40      ,5,/  4a|f4$$If|!vh54&5#v4&#v:V l0      ,,54&52 s2 s4a|$$If|!vh54&5#v4&#v:V l0      ,,54&5/  2 s2 s4a|$$If|!vh5,#v,:V l40      ,5,/ 4a|f4$$If|!vh5,#v,:V l40      ,5,/ 4a|f4$$If|!vh5,#v,:V l4g0      ,5,/  4a|f4@@@ NormalCJ_HaJmH sH tH @@ Heading 1$d@&5\:: Heading 2$@&6]>@> Heading 3$@& 5>*\JJ Heading 5$$@&a$56>*\]@@@ Heading 6$$@&a$5\DA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List PP Quick I.% & F01$7$8$H$^`02>2 Title$a$5\4 @4 Footer  !4B"4 Body Text6]NC@2N Body Text Indentd`6U@A6 Hyperlink >*B*ph.)@Q. Page Number4@b4 3Header  !>@r> J Footnote TextCJaJ@&@@ JFootnote ReferenceH*j@j a= Table Grid7:V0FVF 6FollowedHyperlink >*B* ph.X@. Q2/Emphasis6]HH ^ Balloon TextCJOJQJ^JaJ^&^P^P$ "_/E^P;z} z z z z z z z z "_/<E^P812uvopJK   N O !"*+2>?] < l !!h!|!}!!!! "G""""""" $ $^$_$$%%`&a&''''(())1,2,,,!.".//Z0[0n00000041F1H1b1c111111O2Z2[2222W3b3c3333S4T4q4r46667777x8y8z889Q9R999999:::F:H:I:c:e:f:::K;L;;;<<<<<<<<<<==f=======>">#>$>>>H?I????@@f@@@@@@@A"A#A$AAAHBIBBBBCCbCCCCCCCDDD DDDDEEEEFFGGGGG8GMGNGOGeGfGGGGGGGGGG'HhHiHHHHHHHHHHHHII I IIIGJHJJJJKK|K}KKKKlLmLnLLLLLM)NUNWNYN]N}O~OOOWPXPYPZP_P%%%%%%%%% %%%0*0*0*0*0*0* 0*0* 0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*0*GV0*0*0*0*GV0*0*0*GV0*0*0*0*0*0*0*0*0*ޅ0*0*0*GV0*Q0*GV0*0*GV0*0*GV0*0*0*0*0*0*0*0*GV0*U0*^ jjY8+sj(sj 8+N%jjiN%jj&N%jj&N%jjN%jj8+jA8+v:8+GV8+j8+j8+j8+j8+j8+j8+j8+jN 8+v:8+v:8+v:8+GV8+v:@ )ji)ji)ji)j]A8+jA8+j8+j8+j8+j8+8+8+jN 0*GV0*0*0*0*(0*0*0*0*$jj&$jji$jj&0*j0*j0*j0*j0*j0*j0*p}0*0*0*0*$jj&$jji$jj&0*j0*j0*j0*j0*j0*j0*p}0*0*0*0*$jj&$jji$jj&0*j0*j0*j0*j0*j0*j,+v:,+[ 0*0* jjj 8+jsjsj*8+8+jiN%jN%^N%RN%jN%js[ N%GVN%jN%GVN%jN%jsʰ8+j&8+8+v:8+v:8+v:8+v:8+v:8+v:E8+j8+j8+j8+j8+j8+j8+j 0*v:0*v:0*v:0*v:0*v:0*v:0*v:0*v:0*9%0*0*0*v:%%s%s%s%s%s%s%s%s812uvopJKL   N O !"*+2456789:;<=>?] < l !!h!|!}!!!! "G""""""""" $ $^$_$$%%`&a&''''(())1,2,,,!."./^/_///Z0[0n00000041F1G1H1b1c111111O2Z2[2222W3b3c3333S4T4q4r46667777x8y8z889Q9R999999:::F:H:I:c:e:f:::K;L;;;<<<<<<<<<<==f=======>">#>$>>>H?I????@@f@@@@@@@A"A#A$AAAHBIBBBBCCbCCCCCCCDDD DDDDEEEEEEFFFGGGGG8GMGNGOGeGfGGGGGGGGGGG'HhHiHHHHHHHHHHHHII I IIIGJHJJJJKK|K}KKKKlLmLnLLLLLMNNNNNNNNNN'N(N)NTNUNVNWNXNYNZN[N\N]N}O~OOOWPXPYPZP[P\P_P000000000000X0020202(00 0 0 0 0 0 0 0 0 (00000(0(000000000000000000000000000000000000000000000000000000000000 0 0 0 000000000000000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000 0 0000000 0 00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000 0 0000000000 0 0 0 0 0 0 0 0 000000000000 0 0 0 0 0 0 0 0 000000000000 0 0 0 0 0 0 0 0 0000000000 0 0000 00 00 0 0 0 0 0 0 0 0 0 0 0 0 0 00000 0 0 00000 0 0 0 0 0000000 0 0000000 0 000000000000X000X000X000X00@0@0@0@0@0@0@0@0@00@0X00H 00000000000J812uvopJKL   N O *+ "G"""""" $ $^$_$$%%`&a&''''(())1,!."./^///n000b1c1111O2Z2[2222W3b3c3333S4T4q4r46667x8y8z88999999:::F:H:I:c:e:f:::;<<<<==f=======>">#>$>>@@@@@@A"A#A$AACCCCCCDDD DDGGNGOGGGHHHHHHIIJJLMNTNVNZN_PZ00Z00Z00Z000000X00X00Z00Z00Z00Z00Z0"0&Z0"0%0000@v_00j00j00Z00Z00Z00Z070 Z00dX00X00X0I0 X0I0 X0I0 Z0I0 JZ0I0 j00}8j00|j00z@0Z0(0@0Z00@000Z0+0}Z0+0{Z00@0X0<0X0<0X00 @0Z010yZ010x @0Z0E0@0Z0I0@0@0@0Z0:0r;Z0:0p @0Z040Z00GZ00S Z00OpZ00Z00LZ00MZ00Q Z00M Z00  Z00M Z00K Z00  Z00G Z00G Z00  Z00G Z00E Z00 Z00 Z00 Z00X0 0@0X00X00Z00@0j0;0Yj0;0Yj0;0Y<Lj0;0VZ00QZ00 Z00 Z00 Z00Q Z00Q Z00M Z00M Z00M Z00K Z00G Z00G Z00G Z00G Z00G Z00E Z0 0Z0 0 @0 Z0.0"j0Q0FRj0Q0EZ0.0" @0Z0.0"/Z0.0!Z0.0 Z00G Z00G Z00G Z00G Z00E Z00 Z00 Z00  @0 Z00GZ00GZ00G Z00G Z00G Z00G Z00E Z00 Z00 Z00  @0 Z00GZ00GZ00G Z00G Z00G Z00G Z00E Z00 Z00 Z00  @0 Z00GZ00GZ00GZ00S Z00OpZ00Z00QpZ00  Z00G Z00E Z00 Z00 Z00 Z00Z0 0@0Z00@0 @00J 00G 00G@0@0`~l@0J CCCEEEGGGGGGGGGGGGGGGIIIIIL 7#&*19:V<:ADFHIJ:NQSWGYx-012468:;=DJLNSVX\`belx{}7&|)-9: ;r;;;< ==?<@@DEG HcHHH#IJKLMOPQSTTXXXX YFYrx.3579<>?@ABCEFGHIKMOPQRTUWYZ[]^_acdfghijkuvwyz|~v/8`e+",.,/,/>/^PXXXXXX L!'(/Xb$eUOQR$a($/V='I@x@ ' (  TB  c $Dg TB  c $Dg TB  c $Dg TB   c $Dg TB   c $Dg TB  c $Dg  TB  c $Dg TB  c $Dg TB  c $Dg TB  c $Dg TB  c $Dg TB  c $Dg TB  c $Dg TB  c $Dg TB  c $Dg TB  c $Dg TB  c $Dg TB  c $Dg TB  c $Dg TB  c $Dg  TB  c $Dg TB  c $Dg  TB  c $Dg  TB # c $Dg  t $ s *$o"` f % S (A  ARRA"`p & S 2A Untitled3"`f ' S (A  ARRA"`B S  ?2""7778L;M;;<<>>I?J?AAIBJBDDEEFEKK}K^P%8"P(kt@$<4& T&Vt@'%*4t@LnLt:LLt X ` !`tt4ttt#ddt]]tLnLt :LLtX ` !`ttLnLt:LLtX ` !`ttLnLt:LLtX ` !`ttLnLt:LLtt OLE_LINK9 OLE_LINK10 OLE_LINK11 _Hlt223324920 _Hlt223324921 OLE_LINK7 OLE_LINK8 _Hlt223422567 _Hlt223422568LLL..9/9/_P@@@@ ..:/:/_P 3 9Z 3 7Z 38Z3L7Z3 :Z3L?Z3 6Z3;Z_P_P9*urn:schemas-microsoft-com:office:smarttagsplace=*urn:schemas-microsoft-com:office:smarttags PlaceType=*urn:schemas-microsoft-com:office:smarttags PlaceName 8J\_ $ .MNNNNNNNNNNNNN&N[N\N\P_PP\pr !!(())M0R0?%???B%BBBE!EEEMNNNNNNNNNNNNN&N[N\N\P_P::::::::::::::^/_/_/////^5j5k5k5t7u7:9;9::<<F<<<<<<>>AADDgHHHHHHHHJ KMNNNNNNNNNNNN&N[N\N\N]N\P_P   HT} J &'/25RTUc"^/^5j5MNNNNNNNNNNNNN)NSN[N\N_PDDXr~\o mz!# N<[3"п0['> "~2(H06^2b78n.g#827p Dd@E.Hab`FFcd@\iPfWNp93 :q       `:T^                 %>                %        R        R        6,m),YGw; m> ? & e{@Y#]* 8KZ=6ZfJ\ ""%#$?^%g&k&W=*,3,b,g./Q2/-03 <>Q<g=>]>?\U?@k CD_2E F~FR HHU!LCVM38RbS|]S0Xp[\b.^7ababh\bGc d6fpf!tg9iVjW-k,Om@n-o7oZopp~sxx4|xG|sO|X|k}g/}42Jf17toVAt`Ze~vwCl1$^n9HR@D-lrB :* b!2.^5^q6A+E3 aKg=.r48[ *+a=@ ~B)> Q=T_E'wKHx74yPKzv{zw_C!+;NfL53g)D3aM7K(MW;z' 8'Hckt"""""# $ $$''|(((((((()*1,^//0#0[0n00000041F1G1H1b1c111111O2Z2[2222W3b3c3333S4T466y8z899999:::F:H:I:c:e:f:::<<f=======>">#>f@@@@@@@A"A#AbCCCCCCCDDDEFFGG8GNGOGeGfGGGGGGGGGGGHHHHHHIIJJKKMN\N]NOO_PaJaJaJaJW@0W@0W@0W@0W@0W@0W@0W@0W@0W@0"""CJ@]'()123489=>@ACDH^P@02h@<>@@F@L@P@T@Unknown Gz Times New Roman5Symbol3& z ArialI& ??Arial Unicode MS?Wingdings 25& zaTahoma;Wingdings?5 z Courier NewG WP MathASymbol"1h&&F A' A'!x4dLL- 2qHX ?62APPENDIX TO 2590fieldslndevallX              Oh+'0   @ L X dpxAPPENDIX TO 2590fieldsl Normal.dotndevall2Microsoft Office Word@F#@ok @@ A՜.+,D՜.+,T hp  US Department of Labor'L' APPENDIX TO 2590 Title 8@ _PID_HLINKSA$LRhttp://www.dol.gov/COBRA!6 \\www.irs.govQ- "mailto:NewCobraRights@cms.hhs.govxd/http://www.cms.hhs.gov/COBRAContinuationofCov/3$http://www.dol.gov/ebsa9:http://www.doleta.gov/tradeact  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLNOPQRSTVWXYZ[\aRoot Entry FjcData  1TableKWordDocumentNSummaryInformation(MDocumentSummaryInformation8UCompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q