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Get COBRA/ALTERNATIVE COVERAGE Form (See ... - SelectHealth - Selecthealth

Med PlusSM q Select ChoiceSM* q Select ValueSM * Benefits are administered by SelectHealth, Inc. and underwritten (insured) by SelectHealth q Select Choice PremierSM* q SelectHealth EyewearSM q SelectHealth DentalSM Benefit Assurance Company, Inc. A. EMPLOYEE INFORMATION (Qualified Beneficiary) Qualified Beneficiary (QB) q I would like to enroll in COBRA or; q I would like to enroll in 12 months of alternative coverage (NetCare) and waive my COBRA rights. NetCare Deductible Opt.

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