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Get Anthem 10262CAMEN 2011

On of terminations of employees/dependents }} COBRA/Cal-COBRA notifications – COBRA is for groups of 20 or more – Cal-COBRA applies to groups with 2 to 19 full-time and part-time employees }} Address changes }} Name of person completing form Signature Date / / Due date / / Phone no. ( ) SECTION 1. TERMINATING EMPLOYEES Please submit deletions as they occur. RETROACTIVE CANCELLATIONS ARE NOT ALLOWED. Note: If the employee is Federal COBRA-eligible, PLEASE be sure the em.

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