Common use of COBRA Information Clause in Contracts

COBRA Information. Are you subject to COBRA? Yes No Will Acuity Group administer COBRA coverage? Yes No If no, please provide administrator information: Name: Address: Phone: Fax: Is anyone in your group currently under COBRA, state continuation plan, or within their election period? Yes No If yes, please list below: NOTE: Any COBRA applications received after approval of this application may result in a rate adjustment or declination.

COBRA Information. Are you subject to COBRA? Yes No Will Acuity Group Xxxx Xxxxxx administer COBRA coverage? Yes No If no, please provide administrator information: Name: Address: Phone: Fax: Is anyone in your group currently under COBRA, state continuation plan, or within their election period? Yes No If yes, please list below: NOTE: Any COBRA applications received after approval of this application may result in a rate adjustment or declination.

COBRA Information. Are you subject to COBRA? Yes No Will Acuity Group administer Meritain Administer COBRA coverage? Yes No If no, please provide administrator information: Name: Address: Phone: Fax: Is anyone in your group currently under COBRA, state continuation plan, or within their election period? Yes No If yes, please list below: NOTE: Any COBRA applications received after approval of this application may result in a rate adjustment or declination.

COBRA Information. Are you subject to COBRA? Yes No Will Acuity Group Resources administer COBRA coverage? Yes No If no, please provide administrator information: Name: Address: Phone: Fax: Is anyone in your group currently under COBRA, state continuation plan, or within their election period? Yes No If yes, please list below: NOTE: Any COBRA applications received after approval of this application may result in a rate adjustment or declination.