COBRA Monthly Payment Coupon



COBRA Monthly Payment Coupon

Your Name____________________________________________________________ SSN – 1st 5 digits: ____________________

Address (if changed)_________________________________________________________________________________________

Previous Employer__________________________________________________________________________________________

Payment Month(s)____________________________ Premium Amount $____________

Make payment payable to: COBRA Management Services, LLC

Return to: COBRA Management Services

PO Box 53525

Bellevue, WA 98015

COBRA Monthly Payment Coupon

Your Name____________________________________________________________ SSN – 1st 5 digits: _____________________

Address (if changed)_________________________________________________________________________________________

Previous Employer__________________________________________________________________________________________

Payment Month(s)____________________________ Premium Amount $____________

Make payment payable to: COBRA Management Services, LLC

Return to: COBRA Management Services

PO Box 53525

Bellevue, WA 98015

COBRA Monthly Payment Coupon

Your Name____________________________________________________________ SSN – 1st 5 digits: _____________________

Address (if changed)_________________________________________________________________________________________

Previous Employer__________________________________________________________________________________________

Payment Month(s)____________________________ Premium Amount $____________

Make payment payable to: COBRA Management Services, LLC

Return to: COBRA Management Services

PO Box 53525

Bellevue, WA 98015

-----------------------

MONTHLY BILLS ARE NOT SENT.

Please review the Payment Instructions and remit your premium with these coupons.

MONTHLY BILLS ARE NOT SENT.

Please review the Payment Instructions and remit your premium with these coupons.

MONTHLY BILLS ARE NOT SENT.

Please review the Payment Instructions and remit your premium with these coupons.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download