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HSA Day – National HSA Awareness Day
MHC COBRA Opt-In
Simplify
- Thank You

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HSA Day – National HSA Awareness Day
MHC COBRA Opt-In
Simplify
- Thank You

HSA Day – National HSA Awareness Day
MHC COBRA Opt-In
Simplify
- Thank You

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HSA Day – National HSA Awareness Day
MHC COBRA Opt-In
Simplify
- Thank You

COBRA Opt-In for MHC Members

To confirm that you would like to participate in this program, please complete the form below.

"*" indicates required fields

First Name*

Last Name*

Legal Business Name*

Email*

Phone*

City*

State*

Zip Code*

Benefits Eligible*

COBRA Covered Lives*

A covered employee is defined as any employee participating in a COBRA-eligible plan (medical, dental, vision, etc.)

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Do you wish to move forward as part of this transition to WEX?*

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No

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Please let us know why you are choosing not to transition with WEX. (select all that apply)*

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