Continuation Of Benefits Coverage Election Form printable pdf download

CATHOLIC EMPLOYEE BENEFIT GROUP

1320 Greenway Drive, Suite 170, Irving, TX 75038

Toll-Free Phone: 888-600-7566

Toll Free Fax: 888-580-1363

Continuation of Benefits Coverage Election Form

This form is sent to the last known address of each qualified beneficiary. Please notify Catholic Employee

Benefit Group (“CEBG”) of all address changes. If you desire this Continuation of Benefits coverage, you must

properly complete this form and send in payment as part of the enrollment process required by the Plan

Administrator no later than 45 days from the later of (1) the date coverage is lost due to the qualifying event

(described below) or (2) the date you received notification. If you do not elect coverage by the end of this

period, your right to elect coverage will be lost. It is your responsibility to complete and return this form

with payment to the address indicated on the last page of this form. CEBG nor The Plan Administrator

will be responsible for the receipt of Continuation of Benefits Coverage Election Forms or payments sent by

regular U.S. mail that have arrived delayed.

Explanation of Benefit:

Because the Plan is a “church plan,” it is not subject to the Consolidated Omnibus Budget Reconciliation Act of

1985 (“COBRA”).

However, the Plan nonetheless offers continuation of coverage with the provisions

described in this section. The extended health coverage is referred to as “Continuation of Benefits Coverage.”

If a “Qualified Beneficiary” (as defined below) loses his/her coverage under the benefit programs of the group

health plan as a result of a qualifying event (as described below), he/she has the opportunity for Continuation

of Benefits Coverage for up to 18 months. The benefit programs that are included in the CEBG group health

plan include the Medical and Dental programs.

Only Qualified Beneficiaries are eligible for Continuation of Benefits Coverage. A “Qualified Beneficiary” is an

employee and any eligible dependents who is covered by a CEBG group health plan on the day before

coverage would otherwise end. This employee must have been on the CEBG group health plan at least 6

months. A “Qualified Beneficiary” also includes (1) any child who is born to or placed for adoption with you

during your Continuation of Benefits Coverage period. Each Qualified Beneficiary has a separate election

right and may choose to continue the coverage offered below.

The initial Continuation of Benefits Coverage premium/payment that is due will include both the premium for

the coverage that is retroactive to the date of the Qualifying Event and, in accordance with normal benefit plan

billing procedures, the next month’s premium.

Subsequent payments for coverage must be received by the

First of the Month in order for coverage to remain in place. Failure to make payments prior to the first of the

month shall result in termination of benefits. Once coverage is terminated, Continuation of Benefits

Coverage cannot be reinstated.

 I Elect NOT to continue this group medical/dental coverage for myself and/or eligible dependents.

 I Elect to continue this group medical/dental coverage for myself and/or eligible dependents, as

checked below:

Election:

(Please check the coverage (s) you wish to continue for yourself and/or your eligible

dependents. The coverage(s) elected must have been in force for you on the day immediately preceding your

qualifying event.)

 Medical/Dental

Coverage(s):

Employee Only:

 Medical/Dental

Employee + Spouse:

 Medical/Dental

Employee + Child(ren):

 Medical/Dental

Employee + Family:

Signature: _____________________________ Printed Name: _________________________________

Date: _________________________________

Note: If you elect to continue coverage, please complete Pages 2 and 3 of this form

CEBG Continuation Election Form all dioceses 7 1 2012

Page 1 of 3

KEEP A COPY FOR YOUR FILES.

Continuation Of Benefits Coverage Election Form

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