Minnesota Company, Inc.

 

 

My COBRA


 

 

 

 

 

Personal Data

 

 

Account Number

 

971255

Name

 

Donald Duck

Address

 

100 Lake Rd

City State Zip

 

St.Paul, MN 55123

Gender

 

Male

Phone

 

555-123-4321

Email

 

donald@disney.com

        


 

 

Qualifying Event Data

 

 

Qualifying Event

 

Termination

QE Date

 

8/10/2016

Effective

 

9/1/2016

Status

 

Elected

Maximum Continuation

 

2/28/2018


 

Premium Information

 

Last Full Month Paid

 

Sep 2016

Next Month Due}

 

Oct 2016

Next Full Amount Due

$590.25

   

(Does not reflect over- or underpayment for prior month)

Next Scheduled Rate Change Date

 

1/1/2017

***Please note that the Next Scheduled Rate Change Date will usually be a future date. If the displayed date is prior to or equal to the current month, itís possible that your rates have changed. We will notify you as soon as possible when we receive any rate renewals from the employer.


 

Coverage

 

 

Blue Cross Medical

 

Blue Cross Preferred Dental

 

Vision Service Plan

 

Select FSA

 


Dependents

 

Spouse

 

Daisy Duck

Child

 

Huey Duck

Child

 

Louie Duck

 

 

 

 

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   Minnesota Company, Inc.