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Get Ut Notice Of Right To Continue Health Insurance

Policy for at least 3 months, then you may continue that same benefit for up to 12 months, but you must pay the total monthly premium. Employer Name: Date: Contact Person: Street Address: City: State: Zip: State: Zip: Employee Name: Street Address: City: Date employee first covered by insurance: Reason insurance will stop (voluntary termination, involuntary termination, retirement, death, divorce or legal separation, loss of dependent status, sabbatical, any disability, leave of absence, .

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