31.11.04.10

.10 Election Statement.

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: ______________________________________