Election Form to Continue Health Care Coverage

Please return the completed form by Certified Mail/Return Receipt Requested to:




ATTN: Payroll/Benefits                                 no later than __________

Please check the appropriate box below to indicate which qualifying event is applicable.

[] 8 week Disability/LOA is over
[] Termination of Employment
(Other than for Gross Misconduct)
[] Employee Working Reduced     Hours

[] Employee Eligible for Medicare
[] Divorce or Legal Separation From Covered Employee
[] Death of Covered Employee
[] Dependent Child Reaching Maximum Age