Laserfiche WebLink
NOTICE OF CHANGE IN BENEFITS OR MONTHLY <br />PLAN <br />Date: <br />City of Mounds View <br />TO: FROM: 2401 Highway 10 <br />Mounds View, MN 55112 <br />Effective on <br />the following changes <br />apply to your coverage for continued benefits under the plan <br />identified below: <br />Name of Flan is <br />Your monthly payment amount is changed <br />Q to $ per month. This amount <br />is due beginning with your payment on <br />Date <br />Your benefits are changed in accordance <br />with the enclosed summary. <br />These changes reflect changes in the entire plan to all <br />participants, not just t.o those under the continuation of <br />benefits prog,am. <br />Form COBRA-5 <br />