Fill and Sign the To Activate This Service Read Agreement and Sign the Cbia Form

ELECTION FORM FOR CONTINUATION OF BENEFITS (COBRA) Coverage may be continued under the following conditions: Retirement, termination or layoff - up to 18 months. Effective Date:______ Spouse and/ or child(ren) of deceased or divorced employee – up to 36 months. Date of death or divorce ___ Dependent child reaching maximum age for coverage – up to 36 months. Date child attains the age of 19, ceases to be a full-time student or attains the age of 24. ___________________________________________________________________ Note: It is the employee’s responsibility to notify the Employee Benefits Division when a dependent child ceases to be an eligible dependent or if an employee is divorced. calendar days of the layoff by payment of the regular contribution rates in effect prior to layoff. However, in no event will the continuation of coverage exceed a total of 18 months. Other Insurance: Do you or your dependentHave other coverage? No Yes If yes, complete the following: Name and address of Insurance provider: Name(s) of insured: Effective date: Rates will be adjusted each January 1. Check appropriate block(s) to indicate coverage(s) to be continued. 20___ Monthly premium rates are as follows. Initial Premium $ _________________________ Present Health Plan A Plan B Plan C Plan D (POS) (HMO) Participant Only _____ _____ _____ _____ Participant & Spouse or Child _____ _____ _____ _____ Two or more _____ _____ _____ _____ Individuals Other Other HMO: _____ POS: _____ Participant Only * * Two or more * * individuals For rates for other HMO and POS plans call Employee Benefits, (_____) _____ - _____ Dental Vision Participant only _____ Participant only _____ Two or more _____ Two or more individuals _____ individuals If you are enrolled in an HMO other than Health America or a Point of Service other than Health America, contact the Employee Benefits Division for the correct rates Coverage is to be continued for: Effective date of coverage: Self Spouse Child Two or more children Provide following information for those to be insured: Name Social Security Number Date of Birth READ CAREFULLY!!! I elect to continue coverage for myself and/or my eligible dependents (if applicable) under _________________________ healthcare plan. I understand that: 1. MONTHLY BILLS WILL NOT BE PROVIDED 2. Premiums are due at the first of the month 3. IF PAYMENT IS NOT MADE WITHIN 30 DAYS OF THE DUE DATE, COVERAGE WILL BE CANCELLED AND CANNOT BE REINSTATED. NOTE THAT HEALTHCARE COMPANIES MAY NOT VERIFY COVERAGE DURING THE GRACE PERIOD. 4. Checks should be made payable to _________________________ and sent to Employee Benefits Division _________________________ __________________________________________________ 5. Initial premium payments must be included with the application ___________________ __ Signature of Participant Date Name of Employee: Address: Phone Number: Social Security Number: