Fillable STATE OF ARIZONA COBRA Premium Assistance OPEN ENROLLMENTCHANGE FORM 2009-2010 - benefitoptions az

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STATE OF ARIZONA COBRA Premium Assistance OPEN ENROLLMENT/CHANGE FORM 2009-2010 I DECLINE COBRA COVERAGE AND PREMIUM ASSISTANCE* B1 2009-2010 COBRA WITH PREMIUM ASSISTANCE OPEN ENROLLMENT FORM The new American Recovery and Reinvestment Act of 2009, which the President signed into law on February 17, 2009, includes a 65 percent reduction on the cost of COBRA premiums for up to 9 months. *By declining/waiving my...
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