Continuance Of Group Health Plan Coverage Election Form
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ONTINUANCE
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ROUP
EALTH
LAN
OVERAGE
LECTION
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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:
One Dependent Two or More
Employee
(Spouse or Child)
Dependents
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:
____________________________
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Parent category: Medical