Continuation Election Form Pacificsource Page 2
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3SECTION 5
TYPE OF COVERAGE YOU ARE ELECTING
Please indicate your choice of coverage and your family’s participation level. Please note:
•
You may continue the type of coverage you had (or currently have).
•
Continuation of dental-only coverage is available only if active employees are permitted to waive medical and
elect dental-only coverage, or if you were on a dental-only plan.
For covered employee:
Medical*
Dental
For dependent #1 (named in section 4):
Medical
Dental
For dependent #2 (named in section 4):
Medical
Dental
For dependent #3 (named in section 4):
Medical
Dental
For dependent #4 (named in section 4):
Medical
Dental
For dependent #5 (named in section 4):
Medical
Dental
For dependent #6 (named in section 4):
Medical
Dental
*The Medical plan does not have pediatric dental coverage. You will need to obtain it through another plan in order to be
compliant with ACA.
SECTION 6
SIGNATURE OF QUALIFYING INDIVIDUAL
ACCEPT: I have read and understand the notification of rights on the reverse side. I hereby request continued coverage
as indicated above. I understand that failure to make timely payment of required premiums will result in permanent loss of
this coverage. While under coverage I expressly authorize any licensed physician, hospital, insurance company, or person
that has any record or knowledge of my health or the health of any listed family member to furnish to PacificSource with
any records concerning myself or any family member named on this application for the purpose of collecting information in
connection with a claim for benefits. A photographic copy of the authorization will be as valid as the original.
_______________________________________
_______________________
Signature
Date
DECLINE: I have read and understand the notification of rights to continue health coverage on the reverse side. I hereby
decline continued coverage available to me as a result of the qualifying event indicated above.
_______________________________________
_______________________
Signature
Date
Please see next page for important information.
Reset Continuation Form
Group Coverage Continuation Election Form OR 1014
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Parent category: Medical