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Get COBRA Form I

N Name: Last, First, Middle Home Address Date of Birth: Social Security Number Street / / No. of Dependent Children: Date of Hire: __/__/___ City State Marital Status: … Single Zip … Married Policy Number: COBRA Rights Information This notice contains information about your right to continue your health care coverage in the [Enter name of group health plan] (the Plan). Please read the information in this notice very carefully. To elect COBRA continuation coverage, follow the inst.

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