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1 Cameron Hill Circle Chattanooga, TN 374020001 bcbst.com COBRA Coverage Continuation Notice Note: This form should be completed by the employer and immediately sent to Blue Cross Bluesier of Tennessee.

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8. Sign and date the form, as per the provided instructions. In some cases, you may need a witness or notary present during the signing process.
9. Make a copy of the completed and signed form for your own records before submitting it as instructed. Retaining a copy can be useful for future reference or for your own personal records.

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