Letter Of Acknowledgement

Name___________________________________________

The Gates Auto Group benefits packet received includes:

1. Department of Labor New Health Insurance Marketplace Coverage Options and

Your Health Coverage.

2. Continuation Coverage Rights Under Cobra

3. Gates Auto Group - July 1, 2015 to June 30, 2016 Group Health Benefits Overview

4. Summary of Benefits and Coverage

-HDHP AGG/7050 - D5000

-HDHP AGG/10070 - D2500
-NPOS COPAYF/7050 - D3000
-NPOS COPAYF/7050 - D2000

I acknowledge:

1. I have read the Department of Labor New Health Insurance Marketplace Coverage
Options and Your Health Insurance Coverage.

Signature______________________________________________Date__________

2. I have read the Continuation of Coverage Rights Under Cobra.

Signature______________________________________________Date__________

3. I have received the Group Health Benefits Overview.

Signature______________________________________________Date__________

4. I have received the 4 Summary of Benefits and Coverage noted above.

Signature_____________________________________________Date__________