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| Cobra Election Form |
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| Name: |
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| Address: |
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| I elect to continue group health coverage under COBRA legislation: |
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| YES |
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NO |
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| I elect to continue group dental coverage under COBRA legislation: |
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| YES |
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NO |
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| List all individuals to be covered, including the policyholder (if applicable). Only individuals who are insured prior to the qualifying event are eligible for COBRA |
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| NAME |
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BIRTHDATE |
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SOCIAL SECURITY # |
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| (Policyholder) |
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| (Spouse) |
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| (Dependent) |
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| (Dependent) |
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| (Dependent) |
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| Policyholder Signature |
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Date |
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| Continuation Coverage: |
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| Policy Holder: |
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| Spouse: |
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| Dependents: |
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| TOTAL: |
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