Get Utah Insurance Department Continuation Coverage Election Notice Form 2019-2025

This guide is designed to assist you in completing the Utah Insurance Department Continuation Coverage Election Notice Form online. It provides clear, step-by-step instructions to help you understand the form and ensure that you submit it correctly.

Follow the steps to complete the form efficiently.

1. Click ‘Get Form’ button to download the form and open it in your preferred document editor.
2. Begin by entering the date of the notice at the top of the form.
3. Identify the qualified beneficiary or beneficiaries by name or status in the designated section of the form.
4. Fill out the name of the group health plan as indicated on the form.
5. Complete the checkboxes under the reasons for loss of coverage, making sure to select all that apply.
6. Identify each person entitled to elect continuation coverage by filling out their name, date of birth, relationship to the employee, and social security number or other identifier.
7. Sign and date the form to validate your election of continuation coverage.
8. Provide your printed name, relationship to the individuals listed, and your current address and telephone number.
9. Review all the information for accuracy and ensure that all required fields are completed.
10. After completing, save your changes. You may download, print, or share the form through the options available in your document editor.

Complete the Utah Insurance Department Continuation Coverage Election Notice Form online to ensure your health care coverage continues without interruption.