/ COBRA IMPORTANT! Payment required for activation of COBRA coverage. Remit with form directly to HealthPass. Employee Election Dependent s Election.

 

/ COBRA IMPORTANT! Payment required for activation of COBRA coverage. Remit with form directly to HealthPass. Employee Election Dependent s Election.

 

/ COBRA IMPORTANT! Payment required for activation of COBRA coverage. Remit with form directly to HealthPass. Employee Election Dependent s Election.

 

/ COBRA IMPORTANT! Please remit COBRA payment with form directly to HealthPass. Employee Election Dependent s Election Start date.

 

/ COBRA IMPORTANT! Payment required for activation of COBRA coverage. Remit with form directly to HealthPass. Employee Election Dependent s Election.

 

Status Change PT to FT on / / Involuntary loss of coverage / / Add Dependent Birth on / / Other describe Terminations / Changes Voluntary Involuntary Medical Dental EverGuard.

 

/ COBRA IMPORTANT! Payment required for activation of COBRA coverage. Remit with form directly to HealthPass. Employee Election Dependent s Election.

 

Status Change PT to FT on / / Involuntary loss of coverage / / Add Dependent Birth on / / Other describe Terminations / Changes Voluntary Involuntary Medical Dental EverGuard.

 

/ COBRA IMPORTANT! Payment required for activation of COBRA coverage. Remit with form directly to HealthPass. Employee Election Dependent s Election.

 

P. O. Box 22999, Rochester, NY 14692 A nonprofit independent licensee of the BlueCross BlueShield Association Instructions on Back. All Dates mm/dd/yy ‰ Check if name change.

 

/ COBRA IMPORTANT! Payment required for activation of COBRA coverage. Remit with form directly to HealthPass. Employee Election Dependent s Election.

 

P. O. Box 22999, Rochester, NY 14692 A nonprofit independent licensee of the BlueCross BlueShield Association Instructions on Back. All Dates mm/dd/yy ‰ Check if name change.

 

/ COBRA IMPORTANT! Payment required for activation of COBRA coverage. Remit with form directly to HealthPass. Employee Election Dependent s Election.

 

/ COBRA IMPORTANT! Payment required for activation of COBRA coverage. Remit with form directly to HealthPass. Employee Election Dependent s Election.

 

/ COBRA IMPORTANT! Payment required for activation of COBRA coverage. Remit with form directly to HealthPass. Employee Election Dependent s Election.

 

/ COBRA IMPORTANT! Payment required for activation of COBRA coverage. Remit with form directly to HealthPass. Employee Election Dependent s Election.

 

/ COBRA IMPORTANT! Payment required for activation of COBRA coverage. Remit with form directly to HealthPass. Employee Election Dependent s Election.

 

/ COBRA IMPORTANT! Payment required for activation of COBRA coverage. Remit with form directly to HealthPass. Employee Election Dependent s Election.

 

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Deceased Marriage certificate or divorce docum entation required. Divorc e requires address of ex-spouse for Cobra notification. Requested Medical Coverage:.

 

Versi  Instr EnroBene  SEffe Date Mari WorkWork Sect ion date 09/2 ructions oeficiaryChanS upplemen t ctive Date: t ion I– Empp loyeeInfori.

 

PENNSYLVANIA STATE SYSTEM OF HIGHER EDUCATION ANNUITANT HEALTH CARE PROGRAM GROUP BARGAINING UNIT PERSONNEL EMP/ANN PREMIUM EFFECTIVE.

 

GEF02-1 Please Retain A Copy Of The Fully-Completed Form For Your ADM Records And Return The Original To Your Employer Continued on Following Page 1 Washington.