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Get Cobra Medical Coverage Continuation Form 2006

Ht to continue your health care coverage in the Sample Company, Inc. Group Health Plan (the Plan). Please read the information contained in this notice very carefully. To elect COBRA continuation coverage, follow the instructions on the next page to complete the enclosed Election Form and submit it to us. If you do not elect COBRA continuation coverage, your coverage under the Plan will end at 12:01 AM on 1/31/2006 due to end of employment. If elected, COBRA continuation coverage will begin on 1.

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