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Get Wisconsin State Continuation Sample Form

85 TO BE COMPLETED BY EMPLOYER ONLY Employee Name First Middle Initial Last Date of Hire - STATE CONTINUATION OF COVERAGE Applicable to employers with less than 20 employees and church and federal government groups COBRA Applicable to employer with 20 or more employees FOR STATE CONTINUATION OF COVERAGE OR WHEN THE EMPLOYER DOES COBRA BILLING IF YOU ELECT TO CONTINUE COVERAGE PAYMENT MUST BE SENT TO PAYABLE ON OR BEFORE THE DAY OF EACH MONTH COMM.

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