P.O. Box 655730 COBRA - Continuation of Dallas, Texas 75265-5730 ...
Dallas, Texas 75265-5730 Coverage Application and Social Security Disability Extension Form No. COBRA06 2 05253.1106 Termination of COBRA coverage A qualified beneficiary’s right to COBRA continuation of coverage will be terminated when: • Any required premium is not paid in full on time; ................
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