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.
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