Colorado house bill health 1353 2003 form: Fill out & sign online

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Click ‘Get Form’ to open the Colorado House Bill Health 1353 2003 form in the editor.
Begin by entering the Business Name and Group Number at the top of the form. This identifies your organization and its insurance group.
Fill in the Business Address, Employee Name, Social Security Number, and Job Term Date. Ensure accuracy as this information is crucial for processing.
Indicate the effective termination date of coverage. This should be the last day of employment or when hours are reduced below minimum requirements.
Specify your continuation preference by selecting either medical or dental coverage options. Remember, dental can only be continued if combined with medical coverage.
Sign and date the form to confirm your choices and understanding of premium payment deadlines.

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