COBRA Notice Opt-Out Request - Admin America

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Submit an Opt-Out Request by Completing the Below Questions
By completing this form, I am instructing Admin America to not send the notices required by ARPA to the Qualified Beneficiaries of the designated employer.
Employer Name*
Authorized Representative's Name*
First Last
Authorized Representative's Email*
The details of your submission will be sent to the email address provided below.
Additional Email(s) (optional)
The details of your submission will be sent to the email address(es) provided below.

To send to multiple email addresses, separate the email addresses with a comma.

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COBRA Notice Opt-Out
Check the box below to Opt-Out of the AEI COBRA Notices
Opt-Out

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Opt-Out Agreement
By entering your name below you are hereby signing this document and agreeing that you are an authorized representative that has been entrusted to submit this opt-out request.

Signature*

Date*
MM slash DD slash YYYY

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