The form which the insured shall use to elect coverage under these regulations shall be in language substantially as indicated in this regulation:
( 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: ______________________________________