Md. Code Regs. 31.11.04.10
Current through Register Vol. 51, No. 12, June 14, 2024
The form which the insured shall use to elect coverage under these regulations shall be in language substantially as indicated in this regulation:
| To ___________________________________________ ( name of employer) |
| I _____________________________ whose Social Security ( name of employee) |
| number is __________________________ have been ( number ) |
| terminated as an employee on ______________________. (date of termination) |
Before termination I was covered under the employer's group health insurance contract (check one)
____ for myself.
____ for myself and dependents.
I elect to have this coverage continue in force and I agree to pay the required premium.
Date of Application: __________________________________
Signature of Insured: _________________________________
Mailing Address: ______________________________________
Md. Code Regs. 31.11.04.10