City Of New York Employee Benefits Program Continuation Of Coverage Application Page 2
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8CITY OF NEW YORK EMPLOYEE BENEFITS PROGRAM
CONTINUATION OF COVERAGE APPLICATION
Date of Qualifying Event
/
/
REASON FOR SUBMISSION (PLEASE PRINT CLEARLY) (CHECK ONE)
/
T
ermination of Employment/Member
Reduction of Work Schedule
Divorce or Legal Separation
Termination of Domestic Partnership
Death of Employee/Retiree
Loss of Eligibility as a Dependent Child
Social Secruity Number:
Present or Former
Present or former Contract
Health Plan:
Holder’s Name:
Self
}
Present or Former City
Relationship to
Spouse (former or current)
Employee’s Welfare Fund:
Present or
Domestic Partner
Former Contract
Son
Holder
Daughter
APPLICANT INFORMATION (PLEASE PRINT)
Last Name:
First Name:
M.I.:
Social Security Number:
Home Telephone #:
(
)
Mailing Address:
Apt.:
Date of Birth:
Sex:
Male
Female
City:
State:
Zip Code:
Marital Status:
Married
Single
Widowed
Date of Marital Status Event:
Domestic Partner
Legally Separated
Divorced
/
/
Is Applicant or Any Dependent Covered by Medicare?
Yes
No
If Yes, a COPY of the Medicare Card MUST be attached.
FAMILY INFORMATION (PLEASE LIST ALL PERSONS TO BE COVERED, INCLUDING EMPLOYEE IF APPLICABLE (PLEASE PRINT)
Check if Applicable
Social Security
Date of
Relationship
Full
Perm-
Covered by
First Name
Last Name
Number
Birth
Time
anently
Other Group
Dom.
Student
Disabled
Insurance
Self
Spouse
Son
Daughter
Partner
HEALTH PLAN REQUESTED (
“
”
).
check the box before the plan you want and you must check
yes or no
for the optional rider benefits
Aetna EPO
Cigna Health
DC 37 Med-Team
Empire EPO - Nationwide
Empire HMO - New York
GHI-CBP/EBCBS
GHI HMO
HIP Prime HMO
HIP Prime POS
MetroPlus
Vytra Health Plan
OTHER _______________________________________
Optional Benefits (Please check one):
Yes
No
WELFARE FUND - COBRA
Contact your your union or welfare fund directly for the necessary forms, available options and costs. You will pay the union welfare fund directly for the
cost of these benefits.
AUTHORIZATION
I certify that the above information is correct. I fully understand that I am responsible
I choose to waive my rights to extend my current health coverage under COBRA.
for the full cost of my continuance of coverage and will be subject to the terms and
I wish to convert to a direct payment policy. Please send me a conversion contract.
condictions of the group contract.
/
/
/
/
Applicant’s Signature
Date
Applicant’s Signature
Date
THIS NOTICE MUST BE MAILED DIRECTLY TO YOUR HEALTH PLAN
FOR COBRA CONTINUATION COVERAGE OR FOR DIRECT PAYMENT CONVERSION
(See Plan Description for address)
ebpcobraform06302017.indd
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