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2022 PEBB Continuation Coverage (COBRA) Election/Change

This form replaces all PEBB Continuation Coverage (COBRA) Election/Change forms previously submitted. Therefore, you must complete the entire form, including the dependent section for any children you want to continue to cover. Inaccurate, incomplete, or illegible information may delay coverage. Type or print clearly in dark ink and use all capital

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  Continuation, Coverage, Cobra, Continuation coverage

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