Initial / General Notice of COBRA rights
This packet contains forms for use when an individual first becomes covered
under the plan.
COBRA regulations require that the General, or Initial Notice of COBRA rights must
be sent to the covered individual(s) within 90 days of the date they first become
covered under the plan.
The plan administrator should retain proof that this notice was sent to the last known
address of the covered individual(s).
The above listed notices were sent to the following:
Date of Notice
05/19/2014
Name of Individual(s)
Employee: Ash
Spouse Name: NG
Dependent: A,A
Address
NY
City, State, Zipcode
NY, New York, 11001
Notes
1 of 5