Warning: If your notice is late or if you do not follow these notice procedures, you and all related covered individuals will lose the right to any extension of COBRA continuation coverage.
Notices Must Be Written: Any notice that you provide must be in writing and may be mailed or faxed. Oral notice, including notice by telephone, is not acceptable.
When to Send Notices: If mailed, your notice must be postmarked no later than the last day of the applicable notice period. If faxed, your notice must be received no later than the last day of the applicable notice period. (The applicable notice period are described in the paragraphs entitled "How long will COBRA coverage last," "Disability," and "Second Qualifying Event," if applicable to your notice.)
Where to Send Notices:
Multnomah County Employee Benefits Office ATTN: COBRA
501 SE Hawthorne Blvd, Suite 400
Portland, OR 97214
Information Required for All Notices: Any notice you provide must include: (1) the name and address of any employee who is or was covered under the plan; (2) the name(s) and address(es) of all qualified beneficiary(ies) or other individual(s) who lost coverage as a result of the Qualifying Event; (3) the Qualifying Event and the date it happened; and (4) the certification, signature, name, address and telephone number of the person providing the notice.
Additional Information Required for Notice of Disability: Any notice of disability that you provide must include: (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 or other individuals 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; and (6) a statement whether the Social Security Administration has subsequently determined that the disabled Qualified Beneficiary is no longer disabled.
Additional Information Required for Notice of Second Qualifying Event: Any notice of a second qualifying event that you provide must include: (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) documentation that verifies the second qualifying event.
Who May Provide Notices: The covered employee or former employee who is or was covered under the Plan, a Qualified Beneficiary or other individual 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 the responsibility to provide notice on behalf of all individuals who lost coverage due to the Qualifying Event described in the notice.