Please complete, date, sign and return this form to the health plan administrator if you want to receive Continuation or Conversion Coverage. You must respond within 30 days of the date that you receive your Health Care Continuation Notice in order to preserve you continuation, and conversion rights. Other than the first premium payment (due within 30 days of the Notice of loss of coverage under the Plan), the Plan must receive your full monthly premium payment by the first day of the month to which it relates.
