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Main Report
25%
50%
75%
100%
125%
150%
200%
300%
400%
UnitedHealthcare
COBRA Plan Details
Policy Number
:
2222222
Plan Status
:
Active
Client Name
:
ABC BUILDERS INC
Date
:
05
/
22
/
2010
HEALTH 123
Acme Health
25
19
Percentage
2.00
First of Month Following Event
End of month following end of eligibility
Y
Y
Plan Name
:
Carrier Name
:
Plan Dates
:
Division Name
:
Grace Period
:
Dependent Age Limit
:
Student Age Limit
:
Conversion Offered
:
HIPAA
:
Admin Fee
:
Reinstatement
:
Eligibility End
:
02
/
01
/
2010
-
01
/
31
/
2011
0030
Day
(
s
)
Employee Only
Fixed Amount
3.00
Coverage
:
Rate Structure
:
Premium
:
Employee + Child(ren)
Fixed Amount
7.00
Coverage
:
Rate Structure
:
Premium
:
Family
Fixed Amount
10.00
Coverage
:
Rate Structure
:
Premium
:
Employee + Spouse
Fixed Amount
6.00
Coverage
:
Rate Structure
:
Premium
:
Carrier Address
:
Carrier Contact
:
123 MAIN ST, Anytown, WI 55555
Attn: Eligibility
Phone
:
Fax
:
888-888-8888
888-888-8888
Email
:
notanemail@email.com
Customer Service Phone
:
***
END OF PLAN
***
99999999
ICID
#
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