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www.pilot-benefits.com/docs/Cobra-Sample-Letter.pdf

to 36 months in certain events (Death of the employee, Medicare entitlement, Divorce or legal ... Each payment is due to the employer the ______ of the ... Please notify me within 60 days from the date of this letter if you intend to elect COBRA.

www.dol.gov/sites/default/files/ebsa/laws-and-regulations/laws/cobra/model-election-notice.doc

Model COBRA Continuation Coverage Election Notice ... plans (including this Plan) give employees and their families the opportunity to continue ... there's a “ qualifying event” that would result in a loss of coverage under an employer's plan . ... For example, if you move to other coverage you may pay more out of pocket than ...

www.dol.gov/sites/default/files/ebsa/laws-and-regulations/laws/cobra/model-general-notice.doc

Model COBRA Continuation Coverage General Notice ... For example, you may be eligible to buy an individual plan through the ... to the employer;]; or; The employee's becoming entitled to Medicare benefits (under Part A, Part B, or both).

www.grpbenefits.net/New/Forms/cobra_notification.htm

Sample letter to be used for COBRA or State continuance notification. ... As an employee of [Name of Employer] covered by [Group Health Plan Name], you have ...

www.bizfilings.com/toolkit/tools/tools-forms/cobra-rights-notification-letter-template

The COBRA Rights Notification Letter Template contains a model form of the letter that all employees must receive either from their employer or from the benefit ...

ccmhg.com/wp-content/uploads/2012/09/Sample_Initial_Notice.pdf

This notice generally explains COBRA continuation coverage, when it may ... employer, or the employee's becoming entitled to Medicare benefits (under Part A, ...

www.shrm.org/resourcesandtools/tools-and-samples/hr-qa/pages/whatnoticesmustbeprovidedtoqualifiedbeneficiariesundercobra.aspx

Jul 15, 2015 ... Note: Multi-employer plans have special rules for COBRA notice requirements. Failure ... This notice must be provided to each covered employee and each covered spouse of an ... See the DOL's sample COBRA notices here.

www.bds-corp.com/wp-content/uploads/2014/10/COBRA-Election-or-Refusal-Form.doc

COBRA Election (or Refusal) Form. Date Employee Name. Address. On (date) your group coverage, including dependents, in the (employer name) group plan ...

www.connecticare.com/employer/communications/combinedmamini.pdf

SAMPLE FORM OF NOTICE OF CONTINUATION RIGHTS FOR ... Massachusetts employer with 2-19 employees eligible for coverage on the day before a .... benefits required are similar to federal COBRA requirements, with a few substantive ...