import main def mkform(self,agentpath): rec = main.Agent.get_by_id(agentpath) rc = 'ZapIndex' rc = rc + '' rc = rc + '

Cobra Notice

' rc = rc + '
' rc = rc + '' rc = rc + 'Employer Information' rc = rc + '' rc = rc + '' rc = rc + '' rc = rc + '' rc = rc + '' rc = rc + '' rc = rc + '' rc = rc + '' rc = rc + '' rc = rc + '' rc = rc + '' rc = rc + '' rc = rc + '
Employer Name
Address
City, State, Zip
Contact Person
Employee Information
Employee Name
Employee Address
City, State, Zip
Date of qualifying event
Date notice sent
Group coverage ends
Qualifying Event ' rc = rc + '
End of employment' rc = rc + '
Death of Employee' rc = rc + '
Entitlement to Medicare' rc = rc + '
Reduction in hours' rc = rc + '
Divorce or separation' rc = rc + '
Exceeds child age limit' rc = rc + '
' rc = rc + '
' rc = rc + '' rc = rc + '' rc = rc + '' rc = rc + '' rc = rc + '' rc = rc + '
Monthly Cost

MedicalDental
Employee
Spouse
Children
' rc = rc + '
' rc = rc + '
' rc = rc + '' self.response.out.write(rc)