Please Note: It is your responsibility to provide us with all of the necessary information to properly administer your program. These questions provide you with a framework and may not specifically request information pertinent to circumstances unique to your program. It is ultimately your responsibility to provide all necessary details irrespective of the questions provided in this questionnaire.

Plan Information

1. Grace Period for the COBRA premium payment. You must choose one Grace Period for all of your COBRA Plans. The minimum is 30 days. Days
    
2. Premium Due Date. You must choose one Premium Due Date for all of your COBRA Plans. Typically, this is the first of the month. of the Month
    
3. Insignificant Premium Payment Threshold: The Regulations do not provide any guidance. We suggest that you chose a dollar amount or a percentage. Insignificant Premium is premium received that is less than of the total Monthly Contribution Amount.
    
4. Insignificant Premium Payment Policy:
   Accept as partial premium as payment in full, or
   Request the balance of the payment be paid within 30 days of the reminder letter.
    
5. Administration Premium Load and the Social Security Premium Load? Do you wish to apply the standard 2% and the 50% Social Security Disability allowable premium load? Yes No. If no, do you wish an alternative load?
    
6. Location Accounting? If you need accounting by "location", please provide below your desired locations and a code for each one. An example would be: Seattle - 001; Tacoma - 002. This is very flexible and you can create a variety of scenarios.
   
    
7. Medical Reimbursement Account? Yes No.
    
8. Open Enrollment Period? From to . If you have different open enrollment periods for different Plans, please describe below.
   
    
9. Claims During the Election Period.
   Claims will be pended during the Election Period or,
   Paid during the Election Period.
    
10. COBRA Plans. For each COBRA Plan that you offer, please have the following information available. A matrix is attached for your convenience. Go to next section to input your plan information.

• "Carrier" Name - If you have a self-funded Benefit Plan, the name of your "Plan".
• "Policy or Contract" Number - If you have a self-funded Benefit Plan, your preference for a numeric description of your Plan.
• Plan Description - For example: PPO Plan, HMO Plan, Vision Plan, Dental Plan. This description will be printed on the Election Form.
• Next Renewal Date
• Next COBRA Rate Change Date
• Last Date Rates were Effective
• Contractual Rates charged for each rate classification - DO NOT include the premium load. We will calculate this for you and confirm the rate structure.
• Date Active Plan Coverage Ends - The two basic choices are the End of the Month or the Day After the Qualifying Event. If the latter, we will request additional information on pro-rated premium calculations.