Continuance
Of Group Health Plan Coverage Election Form
Carrier enrollment form MUST
accompany this election form!
SECTION
A: TO BE COMPLETED BY EMPLOYER |
Name of Employer
_______________________________ Date
of Notice _______________
Name of Employee
_______________________________ Plan
Number ________________
Continuance Payments:
The Due Date for each payment is the _____
day of each month.
The current monthly payment amounts are as
follows:
|
Employee |
Spouse |
Each Child |
Major Medical |
$ |
$ |
$ |
Dental |
$ |
$ |
$ |
SECTION B:
TO BE COMPLETED BY EMPLOYEE, SPOUSE, OR CHILD |
1. I have been
covered under the employer's group health plan as
[ ] The employee named above
[ ] The spouse of the employee
[ ] A child of the employee
2. My coverage
under the plan has ceased or will cease because of the following qualifying
event:
[ ] Termination of the employee's employment on
____________________________
[ ] The employee's divorce or legal separation on
____________________________
[ ] The death of the employee on
________________________________________
[ ] Ceasing to be an eligible dependent child on
______________________________
3. [ ] I elect not to continue group health
plan coverage.
[ ] I elect to continue group health plan
coverage for
[ ] Myself (name) _________________________, born on
_____________
[ ] My spouse (name) _________________________, born on
_____________
[ ] child(ren) (name) _________________________, born on _____________
[ ] child(ren) (name) _________________________, born on
_____________
[ ] child(ren) (name) _________________________, born on
_____________
4. My initial
payment of $____________ is enclosed for continuance of Major Medical Coverage.
5. I understand
that any request to continue group health plan coverage is subject to the
following:
a. This election form must be sent to the
Employer within 60 days after the later of the qualifying event or the date of
the continuance notice.
b. The full initial monthly payment must
accompany this form.
c. Payment is also required for any retroactive
period of continued coverage. This
payment must be sent to the Employer within 45 days after you complete this
form.
d. Subsequent monthly payments are due on the due
date shown above. Continuance will
cease if payment is not received by the Employer within 31 days after the Due
Date.
6. Your
signature ___________________________________ Date: ________________
Your
Address _________________________________________________________
Send this completed form to: ____________________________
____________________________
____________________________
____________________________
Make checks payable to: ____________________________