COBRA ELECTION (OR)
WAIVER FORM
EMPLOYER'S NAME: ________________________________BRANCH:
____________________
EMPLOYEE'S NAME:
_______________________________________
ADDRESS:
__________________________CITY _____________ST._____ZIP___________
QUALIFYING EVENT:
_____________________________________________________________
LIST ELIGIBLE
PERSONS TO BE COVERED: (PERSONS PREVIOUSLY COVERED ONLY)
NAME
LAST, FIRST MIDDLE DATE OF BIRTH SEX SOC. SEC NUMBER
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
PLAN CODE
____________ MONTHLY RATES _____________
BENEFITS COVERAGE
_____________DEDUCTIBLE _________OUT OF POCKET____________
SEE PREMIUM
CALCULATION FORM ATTACHED TOTAL
MONTHLY PREMIUM
________________
I HEREBY APPLY FOR ENROLLMENT IN THE
_________________________________________
GROUP
HEALTH CONTINUATION PLAN FOR MYSELF AND ELIGIBLE QUALIFIED
DEPENDENTS LISTED ON THIS FORM AND AGREE TO PAY THE PREMIUM AS REQUIRED.
x_______________________________________________ ______________________________
SIGNATURE
DATE:
NOTE: IN ORDER TO
BE ENROLLED IN THE HEALTH BENEFIT CONTINUATION PLAN THIS
ENROLLMENT FORM MUST BE RECEIVED NO LATER THAN
_____________________________
RETURN THE COMPLETED FORM TO:
________________________________________________
I HAVE BEEN
INFORMED OF MY RIGHTS TO CONTINUATION OF HEALTH COVERAGE AND
I DO NOT WISH TO APPLY AT THIS TIME.
I AM AWARE THAT I CAN CHANGE MY
ELECTION WITHIN 60 DAYS OF THE DATE OF MY TERMINATION OF EMPLOYMENT.
x_______________________________________________ ______________________________
SIGNATURE
DATE: