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Health Information Release Form
Sample Dependent Care Receipt
Letter of Medical Necessity
Transit & Parking Requests
Flex Benefits Card Receipt Coversheet
Ortho Treatment Statement
ARRA Required Notice When Eligible for Other Health Coverage
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(800) 633-8818 Opt# 1
flex@goigoe.com
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CobraConnect Website
(800) 633-8818 Opt# 2
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COBRA Timelines
Notice To Plan Administrator Timeline
Triggering Events
Triggering Events Listed in the Statute
Death of the covered employee
Voluntary or involuntary termination of the covered employee's employment (other than by reason of gross misconduct), or reduction of hours of the covered employee's employment
Divorce or legal separation of the covered employee from the employee's spouse
Covered employee becomes entitled to benefits under Medicare
Dependent child ceasing to be a dependent child under the generally applicable requirements of the plan
An employer's bankruptcy (but only with respect to health coverage for retirees and their families)
Normal Maximums
18 Months After Loss of Coverage (caused by the Qualifying Event), for:
Covered Employee's Termination of Employment
Covered Employee's Reduction in Hours
36 Months After Loss of Coverage (caused by the Qualifying Event), for:
Death of the Covered Employee
Divorce or Separation of the Covered Employee From His or Her Spouse
The Covered Employee Becoming Entitled to Medicare Benefits
A Dependent Child Ceasing to be a Dependent Child
Extension Events
Multiple Qualifying Events (Not Involving Medicare Entitlement)
Medicare Entitlement Followed Within 18 Months By Termination of Employment or Reduction in Hours
Disability (29-Months Rule)
Optional Extension of Notice Period with Resulting Mandatory Extension of Coverage Period
Special Bankruptcy Rule
Terminating Events
Failure to pay Premium on time
Other Group Health Plan Coverage subject to pre-existing condition rule (as limited by portability law)
Medicare Entitlement
Employer Ceases to Maintain Any Group Health Plan
Igoe Administrative Services 2007
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