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• � � � • • <br /> Are rates (SINGLE/FAMILY or TIERED)for all coverages attached? ❑ Yes ❑ No <br /> Is 2% included in attached rates? ❑ Yes ❑ No <br /> Does Employer have any non-HCSC coverage? ❑ Yes ❑ No <br /> If Yes, <br /> Other Carrier(s): <br /> Name: <br /> Address: <br /> Cit : State: Zip: <br /> Administrative Contact: Phone Number: Fax Number: <br /> Email Address: <br /> Name: <br /> Address: <br /> Cit : State: Zi : <br /> Administrative Contact: Phone Number: Fax Number: <br /> Email Address: <br /> COBRA coverage begins: ❑ On date of Qualifying Event <br /> ❑ First of month following date of <br /> Qualifying Event <br /> Should 150% of the COBRA premium be charged to participants ❑ Yes ❑ No <br /> eligible for disability extension for the remaining 11 months of COBRA? <br /> (Extension is from 18 months to 29 months when deemed disabled by Social Security) <br /> Is contract provided and signed? ❑ Yes ❑ No <br /> Prior COBRA administrator info: <br /> Name: <br /> Address: <br /> Cit : State: Zip: <br /> Administrative Contact: Phone Number: Fax Number: <br /> Email Address: <br /> HCSC IL GEN ASO BPA Rev. 9.1.10(On-line Version) page 8 <br />