Form Gla-01547 - Cal Cobra Dental Election Form printable pdf download

The Lincoln National Life Insurance Company, PO Box 2616, Omaha, NE 68103-2616

toll free (800) 423-2765

CAL-COBRA DENTAL ELECTION FORM

Group Name: ________________________________________

Group #: _______________________

Group ID: __________

I, ____________________________________________ , choose to continue group Dental coverage for myself and/or family members

(name of employee or spouse)

that are qualified beneficiaries as listed below:

Qualified Beneficiary Name

Social Security #

Relationship To Employee

________________________________________

__________________________________

_____________________________

________________________________________

__________________________________

_____________________________

________________________________________

__________________________________

_____________________________

________________________________________

__________________________________

_____________________________

________________________________________

__________________________________

_____________________________

________________________________________

__________________________________

_____________________________

Employee’s Social Security Number: ______________________________________________________________________________

Date of

Please indicate applicable Qualifying Event(s) and dates:

Qualifying Event

Coverage Loss

Employee’s termination of employment

Employee’s hours reduction

_____________

____________

Employee’s death

Employee’s Medicare entitlement

_____________

____________

Divorce or legal separation

_____________

____________

Child’s loss of dependent status - Reason __________________________________

_____________

____________

Examples: Reached age limit, married, no longer full-time student or financially dependent.

To continue Dental Insurance, you must complete this election form within 60 days from the latest of:

a) the date of the Qualifying Event;

b) the date of the loss of coverage; or

c) the date the Group Policyholder sends notice of the right to continue.

(Date notification was received: ________ /________ /________ )

Each monthly payment after the first payment is due the first day of the insurance month, but must be received by the Employer

no later than the 31st day of the insurance month for which it is due. Failure to make appropriate payment by that day will result

in termination of coverage. There may not be re-enrollment under the Plan.

I understand that premiums for Cal-COBRA continuation will be paid through the employer, unless the Employer has arranged

otherwise. The premium rate will equal 110% for months 1-18 and changed to 150% for months 19-36 of the group rate for the

36 month continuation period.

I understand the eligibility requirements for Dental coverage and declare that I and the dependents listed above are currently

insured under the Plan. I understand that future premiums must be paid in advance in order for coverage to continue. I certify

that the above information is correct. I understand and agree to abide by all of the above statements and Plan requirements.

_______________________________________________________ ________________________ _______________________

Signature of Employee or Spouse

Date

Date of Election

__________________________________________________________________________________________________________

Address, CIty,State, and ZIp

_______________________________________________________ _________________________________________________

Signature of Policyholder / Employer

Date

Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.

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GLA-01547

7/08

Form Gla-01547 - Cal Cobra Dental Election Form

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