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E the employee s name and social security number, and your relationship to the employee. Name of Employee: Social Security Number: Relationship to Employee: ELECTION TO ENROLL IN COBRA CONTINUATION COVERAGE Type of Coverage Check Choice(s) Medical Dental Vision Signature of Person Electing COBRA: Date: This election form must be completed and returned by to the address shown below. If mailed, it must be postmarked by the date shown above. If you elect COBRA continuation coverage, then a.
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