Md. Code Regs. 31.11.03.10
Current through Register Vol. 51, No. 25, December 13, 2024
The form which a qualified secondary beneficiary shall use to elect coverage under these regulations shall be in language substantially as indicated in this regulation:
| To ________________________________________ (name of employer) |
| The employee _______________________________ (name of employee) |
| whose Social Security number was _______________ (number) |
| died on ____________________________________ (date of death) |
| This is to advise that ___________________________ |
| ___________________________________________ (name or names of qualified secondary beneficiaries) |
who were covered as qualified dependents of the employee under the employer's group health insurance contract elect(s) to continue to be covered under that contract beginning with the date of death.
Date of Application: ________________________________
Signature of Qualified Secondary Beneficiary: ______________________________
Mailing Address of Secondary Beneficiary: ______________________________
Md. Code Regs. 31.11.03.10