Continuation Election Form Pacificsource
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1
2
3GROUP COVERAGE
PacificSource Health Plans
CONTINUATION
Membership Department
ELECTION FORM
PO Box 7068
Springfield, OR 97475-0068
(For Oregon groups with 19 or fewer employees)
•
This form is to be completed whether you wish to apply for continuation coverage or decline continuation coverage.
•
To continue coverage, complete all sections. To decline coverage, complete only sections 1, 2, and 6.
•
Return the completed form to PacificSource within 31 days after the last day of coverage under the plan, or within 10
days of receipt of this letter, whichever is later.
Please type or print in ink.
SECTION 1
QUALIFYING INDIVIDUAL INFORMATION
Last Name
First
M.I.
Social Security No.
Group No.
Street Address
City
State
Zip Code
Daytime Phone No.
Date of Birth
Sex
Marital Status
Male
Female
Single
Married/Registered Domestic Partner
Divorced
Separated
Widowed
SECTION 2
QUALIFYING EVENT INFORMATION
I am eligible for continuation of benefits because I lost coverage under the terms of my group health plan due to
(check one):
Termination of employment or reduction in hours
Divorce from a covered employee – Date of event:_____________________
Covered dependent no longer meets eligibility requirements – Date of event:
Death of a covered employee
Is anyone applying for continuation covered by other group insurance?
Yes
No
If yes, name of insured:________________________________ Insurance carrier:_____________________________
If you are not the covered employee, give name and Social Security number of employee who is primary on the policy:
Name:_____________________________________________ Social Security No.:____________________________
SECTION 3
CONTINUATION PREMIUM RATES
After you enroll, each premium payment must be received by the employer before the first day of each month for which
you wish to continue coverage. A grace period of 30 days will be granted for the payment of each premium. Your coverage
will be cancelled if the employer does not receive your premium on time. You may continue any coverage you had before
the qualifying event listed in section 2. Ask your employer if you have questions about this coverage.
Employee + Spouse
Employee + Family
Employee + Children
Employee Only
:
Premium
$
$
$
$
SECTION 4
DEPENDENTS CONTINUING COVERAGE
Please list all dependent family members continuing coverage.
If space is needed for additional dependents, use the back of this form or a separate sheet.
Relationship
Last Name
First Name
M.I.
Birth Date
Sex
1
2
3
4
5
6
Group Coverage Continuation Election Form OR 1014
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Parent category: Medical