Sec. 31.11.04.10. 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: ______________________________________