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Cal-COBRA Continuation Coverage Election Form - Anthem

Cal-COBRA Continuation Coverage Election Form - Anthem 2025

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The document is a Cal-COBRA Continuation Coverage Election Form, which allows employees to elect continuation coverage for themselves and their dependents following a qualifying event such as termination of employment or divorce. It includes sections for employee information, qualifying events, coverage elections, dependent information, payment options, and an applicant signature. The form also outlines important notes regarding insurance requirements and arbitration agreements.

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