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BENEFITS CONTINUANCE FORM ______ Last NameFirst NameEmail Address___ Address___CityPostal Code______Home Photocell Phone______EmployerEmployee #______Start Date (Year/Month/Day)Date Sick Leave Ended

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Gather necessary information, including personal details and coverage details.

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Who needs continuation of coverage form?

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Individuals who are eligible for continuation of coverage benefits, such as employees who have recently lost their job or had a qualifying event that triggers COBRA coverage.

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What is continuation of coverage form?

Continuation of coverage form is a document that allows individuals to continue their existing health insurance coverage for a certain period of time after a qualifying event.

Who is required to file continuation of coverage form?

Generally, individuals who experience a qualifying event that triggers the right to continue coverage are required to file the continuation of coverage form.

How to fill out continuation of coverage form?

The continuation of coverage form can typically be filled out online or through the mail by providing personal information, details of the qualifying event, and payment information.

What is the purpose of continuation of coverage form?

The purpose of the continuation of coverage form is to ensure that individuals have continued access to health insurance coverage after certain life events that would normally result in loss of coverage.

What information must be reported on continuation of coverage form?

Information such as personal details, qualifying event details, payment information, and any other relevant information related to the continuation of coverage may need to be reported on the form.

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