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COBRA Eligibility Form

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This form includes the necessary information that an employer must give to its former employee when that employee seeks to establish continuation coverage under COBRA. This document allows an employer to collect crucial information from the employee to ensure that the employer remains compliant with the COBRA requirements. This COBRA Eligibility Form should be used by every employer that is extending COBRA benefits. This form allows for customization to fit the needs of the employer and includes opportunities to include optional language, such as for additional benefits.

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