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List below all dependents eligible for coverage

Only those dependents previously enrolled on the group plan are eligible for coverage under Cal-COBRA. To add dependents not previously enrolled on your

coverage under the group plan, please see your Evidence of Coverage (EOC) or Certificate of Insurance (COI) booklet for the appropriate provisions.

Relationship

Last name

First name

Date of birth

(month, day, year)

Other health coverage?

Does qualifying elector have Medicare?

Does qualifying elector have Medicare due to disability?

c Yes

c No

c Yes

c No

c Yes

c No

If HMO, Physician name

Phone number

(

)

Relationship

Last name

First name

Date of birth

(month, day, year)

Other health coverage?

Does qualifying elector have Medicare?

Does qualifying elector have Medicare due to disability?

c Yes

c No

c Yes

c No

c Yes

c No

If HMO, Physician name

Phone number

(

)

Relationship

Last name

First name

Date of birth

(month, day, year)

Other health coverage?

Does qualifying elector have Medicare?

Does qualifying elector have Medicare due to disability?

c Yes

c No

c Yes

c No

c Yes

c No

If HMO, Physician name

Phone number

(

)

Important instructions (please read carefully)

Under Cal-COBRA, you or your dependents are required, as a condition of receiving benefits, to notify Blue Shield of the following qualifying

events within 60 days of:

1. The death of the subscriber.

2. The divorce or legal separation of the subscriber from the dependent spouse.

3. The dependent child’s loss of dependent status under the health plan.

4. The subscriber’s entitlement for benefits under Title XVIII of the United States Social Security Act (Medicare).

Failure to notify Blue Shield within the required 60 days will disqualify you from receiving continuation coverage.

Notification of your election to continue coverage must be submitted in writing. Notification must be sent by first-class mail, or other reliable means of

delivery, (including personal delivery, express mail, or a private courier company) to Blue Shield of California within the 60 day period following the later

of: (1) the date of the qualifying event; (2) the date you were provided notification by Blue Shield of the ability to continue coverage under the group

health care services plan by Blue Shield; or (3) the date coverage under the employer’s group health care services plan terminates.

You are required to send the first payment by certified mail or other reliable means of delivery (including personal delivery, express mail, or private

courier company) to Blue Shield of California within 45 days of the date you provided written notification to Blue Shield of the election to continue

coverage. The first dues payment must equal an amount sufficient to pay all required amounts that are due. Failure to submit the correct amount

within the 45 day period will disqualify you from continuation coverage.

Blue Shield of California will accept those individuals already on Cal-COBRA coverage from a prior carrier. If an employer changes to a Blue Shield health

plan, you may continue Cal-COBRA coverage with Blue Shield for the duration of your Cal-COBRA coverage period based on your original qualifying event.

Should the contract between Blue Shield of California and the employer group terminate prior to the date your continuation coverage would end, you

or your dependents may elect to continue Cal-COBRA coverage under the subsequent group health service plan. Additionally, you or your dependents

may apply for individual coverage through Blue Shield of California’s Individual and Family Plans. In either case, you must enroll and submit payment

within 30 days of receiving notification of the termination of the employer’s group plan with Blue Shield of California or you will be disqualified from

receiving any additional benefits.

Notification must be sent to: Blue Shield of California Cal-COBRA, PO Box 629009, El Dorado Hills, CA 95762-9009.