2012 cobra continuation election form

Notice of Right to Elect COBRA Continuation of Flexible Spending Arrangement (FSA) Under Health Care FLEX Plan IF YOU DO NOT RETURN THIS ELECTION FORM WITHIN 60 DAYS FROM THE DATE OF THIS NOTICE, YOU WILL LOSE YOUR RIGHT TO CONTINUE YOUR FSA UNDER COBRA. Date of Notice TO: Qualified Beneficiary Name: Address: City, State, Zip: Entitlement to COBRA The Plan Supervisor
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2012 cobra continuation election form
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