Get Group Administered Texas Nine (9) Month State Continuation Of ...

This guide provides clear and comprehensive instructions on how to complete the Group Administered Texas Nine (9) Month State Continuation Of Insurance Application form online. You will find step-by-step guidance for each section of the form to ensure a smooth application process.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the application form and open it in your preferred editor.
2. Begin by filling out your personal details in the designated fields. This includes your last name, first name, middle initial, sex, date of birth, social security number, and address. Ensure that all your information is accurate and up to date.
3. Provide your group number, subscriber ID number, and the date of coverage termination in the corresponding sections. It is important to input these details correctly to avoid delays in processing your application.
4. List the names and details of all dependents you wish to cover under this continuation. Include their dates of birth, social security numbers, and ensure that you only provide details for eligible dependents.
5. Review the section regarding your understanding and agreement to the terms. Carefully read through the statements related to conditions of eligibility, responsibilities regarding premium payments, and consent for information disclosure.
6. Sign and date the application in the designated area. Note that both the applicant's signature and the employer group representative's signature are required; otherwise, the application may be returned.
7. After completing all sections of the form, you can save any changes made. Choose to download, print, or share the completed application as appropriate before submitting it to your prior employer within the designated timeline.

Complete your application online today to ensure you maintain your coverage.