Get MD Continuation Election Form

MARYLAND CONTINUATION ELECTION FORM I wish to continue coverage under the Name of Company Employee Benefit Plan. I understand that this election is subject to the Plan. I have read and understand the MD Continuation Coverage Notice and the letter that accompanied this election form and both MD Continuation rights and limitations on those rights. YES NO IF YES PLEASE ATTACH A NEW APPLICATION Effective date of continuation coverage First payment is enclosed If first payment is not enclosed you will not be able to access health care coverage until payment is received* Qualifying Event Termination of Employment Death Divorce Type of Insurance Selected Health Dental Vision May not add lines of Insurance until Open Enrollment. Type of Coverage Selected Individual Husband/Wife Parent/Child Family Dependents may not be added until Open Enrollment unless a change in family status occurs. Signature Date Print Name Social Security Number Signature of Witness For Employer to complete Continuation coverage end date Bill to Company Bill to Qualified Beneficiary Billing address City State Zip. YES NO IF YES PLEASE ATTACH A NEW APPLICATION Effective date of continuation coverage First payment is enclosed If first payment is not enclosed you will not be able to access health care coverage until payment is received* Qualifying Event Termination of Employment Death Divorce Type of Insurance Selected Health Dental Vision May not add lines of Insurance until Open Enrollment. Type of Coverage Selected Individual Husband/Wife Parent/Child Family Dependents may not be added until Open Enrollment unless a change in family status occurs. Type of Coverage Selected Individual Husband/Wife Parent/Child Family Dependents may not be added until Open Enrollment unless a change in family status occurs. Signature Date Print Name Social Security Number Signature of Witness For Employer to complete Continuation coverage end date Bill to Company Bill to Qualified Beneficiary Billing address City State Zip. YES NO IF YES PLEASE ATTACH A NEW APPLICATION Effective date of continuation coverage First payment is enclosed If first payment is not enclosed you will not be able to access health care coverage until payment is received* Qualifying Event Termination of Employment Death Divorce Type of Insurance Selected Health Dental Vision May not add lines of Insurance until Open Enrollment. Type of Coverage Selected Individual Husband/Wife Parent/Child Family Dependents may not be added until Open Enrollment unless a change in family status occurs. Signature Date Print Name Social Security Number Signature of Witness For Employer to complete Continuation coverage end date Bill to Company Bill to Qualified Beneficiary Billing address City State Zip. .