•

•

•

•

•

EXHIBIT 1 - Continuation Coverage Rights Under COBRA - General Notice

EXHIBIT 2 - Notice by Employer to Self Insured Plans of COBRA Qualifying Event

EXHIBIT 3 - Notice by Covered Employee/Qualified Beneficiary to Employer of COBRA Qualifying Event (e.g. Divorce, Medicare Entitlement, Death, Disability, Dependent no Longer Qualifying Under the Plan for Coverage)

EXHIBIT 4 - COBRA Qualifying Event Letter with Election Form for Employer to Provide to Qualified Beneficiary

EXHIBIT 5 - Notice of Unavailability of Continuation Coverage Letter for Employer to Provide to Former Employee

Enrollment/Change Form
Flexible Spending Account Enrollment Form
Hawaii Clients Enrollment Form
ValueMax Participants Form

Dental Claim Form
Flexibility Spending Account Withdrawl Request
HRA Debit Card Claim Form
Medical Claim Form
PHF Claim Form
RESTAT Prescription Drug Manual Claim Form
Short Term Disability Claim Form
Vision Care Claim Form

PHI Release Form