Continuation Of Benefits Coverage Election Form Page 2
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3CATHOLIC EMPLOYEE BENEFIT GROUP
1320 Greenway Drive, Suite 170, Irving, TX 75038
Toll-Free Phone: 888-600-7566
Toll Free Fax: 888-580-1363
Employer Or Plan Sponsor
Employer’s Company Name Catholic Employee Benefit Group_Address_1320 Greenway Drive, Suite 170
City_Irving_State_TX__Zip__75038_ Phone 888-600-7566
Group I.D.2008CEBG_Sub-Group Name__Diocese of _______________________________ Sub-Group I.D._________
Location Name___________________________________________________________________ Location Code__________________
Employee (Please Print)
Social Security Number ________-______-________ Name________________________________________________________
Qualifying Event –check one (Both Event Reason And Date Of Event Must Be Completed)
Event Reason:
Death of employee
Employee’s termination of employment (for reasons other than gross misconduct)
Employee’s reduction of hours
Divorce or legal separation
Covered employee becomes entitled to Medicare benefits. Medicare eligibility was due to: Age Disability ESRD (End Stage
Renal Disease)
Dependent child ceases to qualify as a dependent under the Plan
Other
_____________________________________________________________________________________
(must specify reason)
Date of Qualifying Event:
________/________/________
Date Last Worked:
________/________/________
Premium Rates and Remittance: Shown Below are the Monthly Premium Rates and Coverage (s)for Medical/Dental Coverage in force
on the day immediately preceding the qualifying event (Rates are subject to change):
Employee Only
Employee + Spouse
Employee + Dependents
Employee + Family
Eff 7/1/12
Eff 7/1/12
Eff 7/1/12
Eff 7/1/12
$655
$1,310
$1,110
$1,420
Specify Yes:
Employee Only
Employee + Spouse
Employee + Dependents
Employee + Family
YES__________________
YES________________
YES__________________
YES________________
Premium--Date of Qualifying to
End of current month
$__________________________
Premium for Next Month
$ __________________________
TOTAL PREMIUM REMITTANCE
$__________________________**
**Check must be included with this form for enrollment.
CEBG Continuation Election Form all dioceses 7 1 2012
Page 2 of 3
KEEP A COPY FOR YOUR FILES.
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