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FOR INTERNAL USE ONLY EFF DATE 2 MO PMT REC MCR EFF DATE Y087 Page1 Please refer to the attached letter to determine your initial payment amount Check only one box to either elect or reject coverage. 754 Minnesota Ave - Ste E Kansas City KS 66101 COBRA Continuation Coverage Election/Rejection form All Instructions To elect COBRA continuation coverage complete this COBRA Election/Rejection Form and return it to us. If I as an employee reject the self-pay continuation coverage my spouse may...

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