SUMMARY OF COBRA INSURANCE CONTINUATION

Complete this form and return it with your enrollment material to the address below:

Office of Graduate Medical Education
Attn: Housestaff Insurance Coordinator
Fax: 619.543.7850
Mail Code: 8829

I wish to continue my enrollment in the health/dental/vision plans as noted below:
Check:
YES NO	Blue Cross Prudent Buyer (Medical) Check Coverage you Desire	Single 2 Party 3 Party or More
YES NO	Blue Cross California Care (Medical) Check Coverage you Desire	Single 2 Party 3 Party or More
YES NO	Standard Pro Dent (Dental) Check Coverage you Desire	Single 2 Party 3 Party or More
YES NO	Vision Service Plan (VSP) Check Coverage you Desire	Single 2 Party 3 Party or More

Please print your name and provide the information requested below:

NAME

ADDRESS

CITY, STATE, ZIP CODE

PHONE

DEPT/DIV

PHY ID#

RETURN ENROLLMENT MATERIAL TO FAX 619.543.7850 OR MAIL CODE 8829

MedEd Administration:

MedEd Offices:

MedEd Services: