ACME Cobra Election Form 2024 Last Name: First: M.I.: Social Security Number: I elect: Buy Up MEDICAL DENTAL-Delta Dental VISION HDHP Base HDHP Surest Buy Up Base Buy Up Base (Davis) Employee Only $0,00 $0,00 $0,00 $0,00 $0,00 $0,00 $0,00 Employee +       Spouse $0,00 $0,00 $0,00 $0,00 $0,00 $0,00 $0,00 Employee +  Child(ren) $0,00 $0,00 $0,00 $0,00 $0,00 $0,00 $0,00 Employee +  Family $0,00 $0,00 $0,00 $0,00 $0,00 $0,00 $0,00 : : Signature Date NOTE: If you are still in your election period and have not elected COBRA continuation, you must complete the COBRA continuation form you received from Paycom. If you no longer have the form, please contact Paycom at 800-580-4505. Please return this form to ACME within 10 days. Page 13 | ACME | Plan Year 2024 Open Enrollment This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.