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Get Administrative Procedure - Policy Umn

Me Address (Street) Date of Birth Date of Birth (City) Home Phone No. (State) (Zip) Last Day of Employment I. MEDICAL & DENTAL BENEFITS (check one of the following options) I have less than three years of service, and I understand that I am eligible for COBRA continuation only. (Contact your department for application.) I have three or more years of service, and I wish to elect COBRA continuation for up to 18 months, foregoing any University contribution under this Layoff Severance Program.

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