Welcome - Rehn Online



|[pic] |COBRA Insurance |

| |Group Plan Premium Information |

| |(509) 534-0600 ~ (800) 872-8979 ~ cobra@ |

|Complete form for each benefit plan offered (i.e. medical, dental, vision, etc.) |

|Employer Information |

|      | |      |

|Plan Renewal Effective Date | |Open Enrollment Period* |

|      |

|Employer / Organization Name |

|      | |      | |      | |      |

|Employer Mailing Address | |City | |State | |Zip |

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|Employer Contact |

|      | |      |

|Contact Phone | |Contact Email Address |

| We request to cancel COBRA Administration through Rehn & Associates |

|Insurance Carrier Information |

|      |

|Insurance Carrier Name |

|      | |      | |      |

|Insurance Carrier Plan Number | |Insurance Carrier Group/Policy Number | |COBRA Subgroup Number |

|Is your plan Self Insured? | Yes No |

|Is your group a member of a multi-employer trust for insurance?* | Yes No |

|* If YES, Trust/Group Name: |      |

|Make Checks Payable To**: |      |

|      | |      | |      | |      |

|Payment Mailing Address | |City | |State | |Zip |

|      | |      |

|Membership/Billing Contact Name | |Membership/Billing Contact Email Address |

| |

|* Rehn & Associates does not send open enrollment information to COBRA participants. It is the employer’s responsibility to notify COBRA participants of any plan |

|changes. Rehn & Associates will provide a list of active COBRA participants upon request. |

|** Please verify with the insurance carrier that they will invoice and accept payments from Rehn & Associates |

|Send completed form to cobra@ or Rehn & Associates, Attn: COBRA Department, PO Box 5433, Spokane, WA 99205 |

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|Form Completed By | |Date |

|      | |      |

|Phone Number | |Email Address |

|Traditional Rate Structure |

|Specific Plan Name: |      |

|Plan Type (PPO, HDHP, etc.): |      |

| |

|Rate Tier Structure |Final Premium Rate |

| |Rate must include all applicable taxes, ACA & Plan fees |

| |Do not include life, disability (LTD/STD) or supplemental insurance |

| |Do not include the 2% COBRA Administration Fee |

|Employee Only |$      |

|Employee & Spouse |$      |

|Employee & Child |$      |

|Employee & Children |$      |

|Employee, Spouse & Child |$      |

|Employee, Spouse & Children |$      |

|Spouse Only |$      |

|Child Only |$      |

|Children Only |$      |

| |

|If your plan is self insured, send premiums to: |      |

| |Address |

| |      |      |      |

| |City |State |Zip |

|Portion of premium sent to carrier (if any): |      | |

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|      | |      |

|Form Completed By | |Date |

|      | |      |

|Phone Number | |Email Address |

[pic]

|Age Banded Rate Structure |

|Specific Plan Name: |      |

|Plan Type (PPO, HDHP, etc.): |      |

| |

|Rate Increase to Next Tier On |Participant Birth Date 1st of the Month After Participant’s Birth Date Plan Renewal Date |

|Are the rates gender specific, based on geographic location, etc? |No Yes (complete one form for each sub category) |

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Participant Age |Rate* | |Spouse Age |Rate* | |Dependent 21+ Age |Rate* | |Dependent Under 21 Count |Rate* | |0-20 |$      | |0-20 |$      | |21 |$      | |1 |$      | |21 |$      | |21 |$      | |22 |$      | |2 |$      | |22 |$      | |22 |$      | |23 |$      | |3+ |$      | |23 |$      | |23 |$      | |24 |$      | | | | |24 |$      | |24 |$      | |25 |$      | | | | |25 |$      | |25 |$      | |26 |$      | | | | |26 |$      | |26 |$      | | | | | | | |27 |$      | |27 |$      | |* Rate must include all applicable taxes, ACA & Plan fees | |28 |$      | |28 |$      | | | |29 |$      | |29 |$      | |Do not include life, disability (LTD/STD) or supplemental insurance | |30 |$      | |30 |$      | | | |31 |$      | |31 |$      | |Do not include the 2% COBRA Administration Fee | |32 |$      | |32 |$      | | | |33 |$      | |33 |$      | |      | |34 |$      | |34 |$      | | | |35 |$      | |35 |$      | |Form Completed By | |36 |$      | |36 |$      | |      | |37 |$      | |37 |$      | | | |38 |$      | |38 |$      | |Date | |39 |$      | |39 |$      | |      | |40 |$      | |40 |$      | | | |41 |$      | |41 |$      | |Phone Number | |42 |$      | |42 |$      | |      | |43 |$      | |43 |$      | | | |44 |$      | |44 |$      | |Email Address | |45 |$      | |45 |$      | | | |46 |$      | |46 |$      | | | |47 |$      | |47 |$      | | | |48 |$      | |48 |$      | | | |49 |$      | |49 |$      | | | |50 |$      | |50 |$      | | | |51 |$      | |51 |$      | | | |52 |$      | |52 |$      | | | |53 |$      | |53 |$      | | | |54 |$      | |54 |$      | | | |55 |$      | |55 |$      | | | |56 |$      | |56 |$      | | | |57 |$      | |57 |$      | | | |58 |$      | |58 |$      | | | |59 |$      | |59 |$      | | | |60 |$      | |60 |$      | | | |61 |$      | |61 |$      | | | |62 |$      | |62 |$      | |[pic] | |63 |$      | |63 |$      | | | |64+ |$      | |64+ |$      | | | |

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