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Cobra continuation coverage election form
Cobra continuation coverage election form



Cobra continuation coverage election form

Link: Download Cobra continuation coverage election form



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Date added: 06.04.2015
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For more information on COBRA Continuation Coverage, see the resources COBRA Model General Notice | en espanol · COBRA Model Election Notice | en

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Model General Notice (full version). Model COBRA Continuation Coverage Election Notice. (For use by group health plans for qualified beneficiaries who have Utah mini-COBRA Continuation Coverage. Election Notice. [Enter date of notice]. Dear: [Identify the qualified beneficiary(ies), by name or status]. This notice Model COBRA Continuation Coverage Election Notice. (For use by single-employer group health plans). [Enter date of notice]. Dear: [Identify the qualified

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COBRA Continuation Coverage Election Form. Form completion instructions: This notice must be sent to the plan participants and beneficiaries by first class mail Date election period expires. COBRA continuation election form. 20 or more employees. If you wish to apply for COBRA Continuation coverage, please complete Important Information About Your COBRA Continuation Coverage Rights . To continue coverage, complete the enclosed Election Form and return it to theModel Continuation Coverage Election Notice for Pennsylvania Mini-COBRA Coverage. (for coverage beginning on or after June 1, 2010). [Enter date of notice]. make your decision. If you choose to elect COBRA continuation coverage, you should use the election form provided later in this notice. If your coverage ends for Model COBRA Continuation Coverage Election Notice. Instructions. The Department of Labor has developed a model Consolidated Omnibus Budget


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