Continuation Of Benefits Coverage Election Form (Page 3 of 3) in pdf

CATHOLIC EMPLOYEE BENEFIT GROUP

1320 Greenway Drive, Suite 170, Irving, TX 75038

Toll-Free Phone: 888-600-7566

Toll Free Fax: 888-580-1363

Covered Individuals:

Name of Covered Individuals

Sex

Relationship

Birthdate

Social Security No.

(including employee)

Self/Spouse/Child

Mo./Day/Yr.

___________________________

_______

____________________

_________________

________________________

___________________________

_______

____________________

_________________

________________________

___________________________

_______

____________________

_________________

________________________

___________________________

_______

____________________

_________________

________________________

See your benefits administrator for the required form(s):

If the dependent(s) listed is not your natural child, please complete the Statement of Responsibility for a Dependent Child form and submit with this enrollment form.

If dependent is 19 years of age or older (unless otherwise stated in the plan) and a full-time student, complete a Student Dependent Attendance Report form and submit

with this enrollment form.

Other Health Benefits Coverage

Do you or any of your dependents have coverage under any other group health plan or Medicare that you will retain after enrolling in

this health plan?  Yes

 No

If yes, please provide the following information about your/their other insurance coverage:

Primary

Who is covered?

Name of Employer

Other

Policy

Effective

Health Coverage

Covered

offering Other

Insurance

Number

Date

(i.e. employee, spouse,

)

(Medical, Dental, Mcare, Mcaid

Individual

Insurance

Company Name

dependent’s name)

_______________

_____________________

____________________

__________________

___________

_________

___________________

_______________

_____________________

____________________

__________________

___________

_________

___________________

Does this other coverage include any exclusion or limitation with respect to any preexisting conditions?  Yes

 No

If “Yes”, have the limitations for the preexisting conditions been satisfied?  Yes

 No

________________________________________________________________________________________________________________________________________________________________________

Instructions:

You must return this form to your plan administrator along

CEBG USE ONLY

with the total premium remittance on p. 2 to be reinstated.

I represent that the information I have provided in this Continuation Election Form is complete, true and

accurate, to the best of my knowledge. My signature below indicates that I have read and understand this

election form.

____/____/____

Effective Date Of Change

Signature of Beneficiary

_________________________________________________Date ____/____/____

Billing Address: