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Get Paychex Cobra

Complete and forward to Paychex within 30 days of the qualifying event. COMPANY/CLIENT NAME: OFFICE/CLIENT ACCT. # List any individual being removed from the insurance and who should be offered continuation. If more space is needed, attach an extra page. Employee & Dependent Name(s) Gender Birthdate Address Medical Enrollment Tobacco Use Employee YES NO YES NO Spouse YES NO YES NO Dependent YES NO YES NO Dependent YES NO YES NO Dependent YES NO YES NO Depende.

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  • beneficiaries
  • premiums
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  • Continuation
  • delaying
  • Rochester
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