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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.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 ...

www.shrm.org/resourcesandtools/tools-and-samples/hr-forms/pages/cms_009553.aspx

Aug 22, 2014 ... Tools & Samples; Employee Handbooks · Express Requests · How-To ... See NOTE TO EMPLOYER at the end of this notice for additional information.] ... COBRA continuation coverage terminated or will terminate for the following reason: ... _____ A covered employee became entitled to Medicare benefits ...

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.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 ...

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.mass.gov/anf/employee-insurance-and-retirement-benefits/benefit-enrollment/forms/active-employee-forms/cobra-forms.html

FY17 COBRA Notice, Rates and Application · doc format of FY17 COBRA ... use this form to apply for COBRA health insurance benefits if your coverage was ... for COBRA Dental/Vision (only for Managers, Legislators, Legislative Staff and ...

welcome.willis.com/nlrgclientcommunication/Shared%20Documents/COBRA/COBRA%20Administration%20Employer%20Guide.pdf

Qualifying Event. ▫ Termination of Employment. SUPPORTING EMPLOYER TOOLS. ▫ DOL Model General Notice of COBRA Rights. ▫ Sample Initial Notice of ...