NOTICE OF RIGHT TO ELECT CONTINUED HEALTH COVERAGE

(Send this form to HR Simplified with your payment)

Qualifying Event:	TERMINATION
Effective Date of QE:
Effective Date of COBRA Coverage:

REGENTS OF THE UNIVERSITY OF CALIFORNIA
To enroll: Please complete Section 1 through 3. Sign Section 4 and return.

1. PERSONAL INFORMATION:

Last Name

First Name

Middle Initial

Address

City:

State

Zip Code

If the applicant is someone other than the former employee, i.e. spouse or child coverage only, note the employee's name and SS#:

Employee Name:

Employee Social Security Number

2. EMPLOYEE AND FAMILY INFORMATION/ELECTED COVERAGE

	Last Name	First Name	M.I.	Date of Birth	SS#
Self
Spouse
Son/Daughter
Son/Daughter
Son/Daughter
Son/Daughter

Legend: EO = Employee Only; SD = Employee and 1 dependent; M = 3 or more

3. PAYMENT

Make your check payable to H.R. Simplified.
Payment enclosed: NO YES Amount $

4. PLEASE READ AND SIGN

I elect to continue coverage under the terms of the plan. I agree to make retroactive payment for all coverage following the date coverage ended, and to make future monthly payments as required. I understand that coverage will end if payment is not made when due, or if I or any other family members applying for coverage become covered under another employee's group plan or become entitled to Medicare. If I or any covered family member becomes ineligible, I will promptly notify H.R. Simplified.

Applicant's Signature

Date:

PLEASE RETURN THIS FORM TO:
(Retain a copy for your files)

HR Simplified
8441 Wayzata Blvd., #300
Minneapolis, MN 55426

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