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NOTICE OF CANCELLATION OR TERMINATION OF <br />HEALTH BENEFITS <br />TO: Date: <br />Qualified Beneficiary Name <br />and Address <br />You are hereby notified that your continuation group health <br />coverage terminated or will be terminated on <br />for the reason checked below. <br />No benefits are payable for services after that date. There <br />is NO reinstatement. <br />❑ 1. Continuation of health benefits were waived. <br />❑ 2. Failure to make election during 60 day election <br />period. <br />❑ 3. Coverage under another group health plan. <br />❑ 4. Eligibility for Medicare benefits. <br />❑ 5. Passsje of. 18 months from qualifying event. <br />❑ 6. Passage of 36 months from qualifying event. <br />❑ 7. Failure to make monthly payment on time. <br />[j 8. Termination of health plan. <br />If you believe termination or cancellation is incorrect, <br />please submit your reasons and any supporting documents in <br />writing immediately. You also have a right to appeal this <br />decision by submitting your appeal, together with supporting <br />documentation, in writing within 30 days of the date of phis <br />notice to: <br />City of Mounds View <br />2401 Highway 10 <br />Mounds View, MN 55112 <br />(612) 784-3055 <br />You will be notified of the decision regarding your appeal <br />within 60 days of receipt of your appeal (or within 120 <br />days, under certain circumstances). <br />Form COBRA-6 <br />