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\trftsWidth1\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw15 \trbrdrl\brdrs\brdrw15 \trbrdrb\brdrs\brdrw15 \trbrdrr\brdrs\brdrw15 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15 \trftsWidth1\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw15 \clshdng2000\cltxlrtb\clftsWidth3\clwWidth11016\clshdngraw2000 \cellx10908\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \ab\af0\afs24 \ltrch\fcs0 \b\fs24\insrsid5008419 HEALTH INSURANCE}{\rtlch\fcs1 \ab\af0\afs24 \ltrch\fcs0 \b\fs24\insrsid96202 - 10 Days Notification Period}{\rtlch\fcs1 \ab\af0\afs24 \ltrch\fcs0 \b\fs24\insrsid5008419 \cell }\pard \ltrpar \ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5008419 \trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw15 \trbrdrl\brdrs\brdrw15 \trbrdrb \brdrs\brdrw15 \trbrdrr\brdrs\brdrw15 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15 \trftsWidth1\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb \brdrnone \clbrdrr\brdrs\brdrw15 \clshdng2000\cltxlrtb\clftsWidth3\clwWidth11016\clshdngraw2000 \cellx10908\row \ltrrow}\trowd \irow3\irowband3\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw15 \trbrdrl\brdrs\brdrw15 \trbrdrb\brdrs\brdrw15 \trbrdrr \brdrs\brdrw15 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15 \trftsWidth1\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrnone \clbrdrr \brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af10\afs28 \ltrch\fcs0 \f10\fs28\insrsid5008419 \'71}{ \rtlch\fcs1 \ab\af0\afs24 \ltrch\fcs0 \b\fs24\insrsid5008419 }{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid5008419 Continue Coverage}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid7738937 - please send me election form}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid5008419 \tab }{\rtlch\fcs1 \af10\afs28 \ltrch\fcs0 \f10\fs28\insrsid5008419 \'71}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid5008419 Do Not Continue Coverage}{\rtlch\fcs1 \ab\af0\afs24 \ltrch\fcs0 \b\fs24\insrsid5008419 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5008419 \trowd \irow3\irowband3\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw15 \trbrdrl\brdrs\brdrw15 \trbrdrb\brdrs\brdrw15 \trbrdrr\brdrs\brdrw15 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15 \trftsWidth1\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\trowd \irow4\irowband4\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw15 \trbrdrl\brdrs\brdrw15 \trbrdrb\brdrs\brdrw15 \trbrdrr \brdrs\brdrw15 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15 \trftsWidth1\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrnone \clbrdrr \brdrs\brdrw15 \clshdng2000\cltxlrtb\clftsWidth3\clwWidth11016\clshdngraw2000 \cellx10908\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \ab\af0\afs24 \ltrch\fcs0 \b\fs24\insrsid5008419 DENTAL INSURANCE}{\rtlch\fcs1 \ab\af0\afs24 \ltrch\fcs0 \b\fs24\insrsid96202 - 10 Days Notification Period}{\rtlch\fcs1 \ab\af0\afs24 \ltrch\fcs0 \b\fs24\insrsid5008419 \cell }\pard \ltrpar \ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5008419 \trowd \irow4\irowband4\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw15 \trbrdrl\brdrs\brdrw15 \trbrdrb \brdrs\brdrw15 \trbrdrr\brdrs\brdrw15 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15 \trftsWidth1\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb \brdrnone \clbrdrr\brdrs\brdrw15 \clshdng2000\cltxlrtb\clftsWidth3\clwWidth11016\clshdngraw2000 \cellx10908\row \ltrrow}\trowd \irow5\irowband5\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw15 \trbrdrl\brdrs\brdrw15 \trbrdrb\brdrs\brdrw15 \trbrdrr \brdrs\brdrw15 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15 \trftsWidth1\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr \brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af10\afs28 \ltrch\fcs0 \f10\fs28\insrsid5008419 \'71}{ \rtlch\fcs1 \ab\af0\afs24 \ltrch\fcs0 \b\fs24\insrsid5008419 }{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid5008419 Continue Coverage}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid7738937 - please send me election form}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid5008419 \tab }{\rtlch\fcs1 \af10\afs28 \ltrch\fcs0 \f10\fs28\insrsid5008419 \'71}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid5008419 Do Not Continue Coverage}{\rtlch\fcs1 \ab\af0\afs24 \ltrch\fcs0 \b\fs24\insrsid5008419 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5008419 \trowd \irow5\irowband5\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw15 \trbrdrl\brdrs\brdrw15 \trbrdrb\brdrs\brdrw15 \trbrdrr\brdrs\brdrw15 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15 \trftsWidth1\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\trowd \irow6\irowband6\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw15 \trbrdrl\brdrs\brdrw15 \trbrdrb\brdrs\brdrw15 \trbrdrr \brdrs\brdrw15 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15 \trftsWidth1\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblrsid13381678\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw15 \clshdng2000\cltxlrtb\clftsWidth3\clwWidth11016\clshdngraw2000 \cellx10908\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13381678 {\rtlch\fcs1 \ab\af0\afs24 \ltrch\fcs0 \b\fs24\insrsid7738937 VISION INSURANCE}{\rtlch\fcs1 \ab\af0\afs24 \ltrch\fcs0 \b\fs24\insrsid96202 - 10 Days Notification Period}{\rtlch\fcs1 \ab\af0\afs24 \ltrch\fcs0 \b\fs24\insrsid7738937 \cell }\pard \ltrpar \ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7738937 \trowd \irow6\irowband6\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw15 \trbrdrl\brdrs\brdrw15 \trbrdrb \brdrs\brdrw15 \trbrdrr\brdrs\brdrw15 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15 \trftsWidth1\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblrsid13381678\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl \brdrs\brdrw15 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw15 \clshdng2000\cltxlrtb\clftsWidth3\clwWidth11016\clshdngraw2000 \cellx10908\row \ltrrow}\trowd \irow7\irowband7\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw15 \trbrdrl\brdrs\brdrw15 \trbrdrb\brdrs\brdrw15 \trbrdrr\brdrs\brdrw15 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15 \trftsWidth1\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblrsid13381678\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl \brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13381678 { \rtlch\fcs1 \af10\afs28 \ltrch\fcs0 \f10\fs28\insrsid7738937 \'71}{\rtlch\fcs1 \ab\af0\afs24 \ltrch\fcs0 \b\fs24\insrsid7738937 }{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid7738937 Continue Coverage\tab }{\rtlch\fcs1 \af10\afs28 \ltrch\fcs0 \f10\fs28\insrsid7738937 \'71}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid7738937 Do Not Continue Coverage}{\rtlch\fcs1 \ab\af0\afs24 \ltrch\fcs0 \b\fs24\insrsid7738937 \cell }\pard \ltrpar \ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7738937 \trowd \irow7\irowband7\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw15 \trbrdrl\brdrs\brdrw15 \trbrdrb \brdrs\brdrw15 \trbrdrr\brdrs\brdrw15 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15 \trftsWidth1\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblrsid13381678\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl \brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5008419 \par \par \ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw15 \trbrdrl\brdrs\brdrw15 \trbrdrb\brdrs\brdrw15 \trbrdrr\brdrs\brdrw15 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth8118\clshdrawnil \cellx8010\clvertalt\clbrdrt \brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2898\clshdrawnil \cellx10908\pard \ltrpar\qj \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid5008419 Employee Signature\cell Date \par \par \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid5008419 \trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw15 \trbrdrl\brdrs\brdrw15 \trbrdrb\brdrs\brdrw15 \trbrdrr\brdrs\brdrw15 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb \brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth8118\clshdrawnil \cellx8010\clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2898\clshdrawnil \cellx10908 \row }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5008419 \par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs28 \ltrch\fcs0 \fs28\insrsid5008419 Return this completed form to your Personnel Office \par \par }\pard \ltrpar\qj \li0\ri0\widctlpar\tx3150\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af10\afs28 \ltrch\fcs0 \f10\fs28\insrsid5008419 \'71}{\rtlch\fcs1 \af0\afs28 \ltrch\fcs0 \fs28\insrsid5008419 }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5008419 Life Insurance Copy}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid5008419 \tab }{\rtlch\fcs1 \af10\afs28 \ltrch\fcs0 \f10\fs28\insrsid5008419 \'71}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid5008419 }{ \rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5008419 Health & Dental Copy}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid5008419 \tab }{\rtlch\fcs1 \af10\afs28 \ltrch\fcs0 \f10\fs28\insrsid5008419 \'71}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid5008419 }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5008419 Human Resources Copy (Submit with HRP) \par }{\rtlch\fcs1 \af0\afs28 \ltrch\fcs0 \fs28\insrsid5008419 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\tx3150\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af10\afs28 \ltrch\fcs0 \f10\fs28\insrsid5008419 \'71}{\rtlch\fcs1 \af0\afs28 \ltrch\fcs0 \fs28\insrsid5008419 }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5008419 Departmental Personnel Copy\tab }{\rtlch\fcs1 \af10\afs28 \ltrch\fcs0 \f10\fs28\insrsid5008419 \'71}{\rtlch\fcs1 \af0\afs28 \ltrch\fcs0 \fs28\insrsid5008419 }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5008419 Employee Copy \page \par \ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft-108\trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clshdng2000\cltxlrtb\clftsWidth3\clwWidth11016\clshdngraw2000 \cellx10908\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\tx3150\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \ab\af0\afs23 \ltrch\fcs0 \b\fs23\insrsid5008419 RULES & PROCEDURES}{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 \trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft-108\trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clshdng2000\cltxlrtb\clftsWidth3\clwWidth11016\clshdngraw2000 \cellx10908\row }\pard \ltrpar\qj \li0\ri0\widctlpar\tx3150\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 \par After you separate from service or begin a leave of absence, State and Federal law allows you to elect the continuation of certain benefit plans which you now have. }{\rtlch\fcs1 \ab\af0\afs23 \ltrch\fcs0 \b\fs23\insrsid5008419 IT IS IMPORTANT TO NOTE THAT YOU HAVE A }{\rtlch\fcs1 \ab\af0\afs23 \ltrch\fcs0 \b\fs23\ul\insrsid5008419 SPECIFIC}{\rtlch\fcs1 \ab\af0\afs23 \ltrch\fcs0 \b\fs23\insrsid5008419 NUMBE R OF DAYS FROM YOUR TERMINATION DATE OR THE BEGINNING OF YOUR LEAVE OF ABSENCE TO NOTIFY THE PLAN ADMINISTRATOR(S) WHETHER OR NOT YOU WISH TO CONTINUE YOUR BENEFIT COVERAGE. \par \par IF YOU ELECT TO CONTINUE: \par \par }{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 Check the }{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\ul\insrsid5008419 Continue Coverage}{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 box beside the plan(s) for which you wish to continue your participation. A copy of this form will be sent to the Plan Administrator(s) for which you have elected continuation of coverage; and subsequently you will be notified directly by mail of your eligibility, your benefit am ount, its duration, and your costs for continuing this coverage. \par \par }{\rtlch\fcs1 \ab\af0\afs23 \ltrch\fcs0 \b\fs23\insrsid5008419 IF YOU ELECT }{\rtlch\fcs1 \ab\af0\afs23 \ltrch\fcs0 \b\fs23\ul\insrsid5008419 NOT}{\rtlch\fcs1 \ab\af0\afs23 \ltrch\fcs0 \b\fs23\insrsid5008419 TO CONTINUE: \par \par }{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 Check the }{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\ul\insrsid5008419 Do Not Continue Coverage}{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 box in each of the areas for which you are declining continuation of coverage. \par \par If you elect not to continue coverage at this time, you will not receive further notification from your Plan Administrator(s); and if you change your mind within the Notification Period of your intent to participate, it is your sole responsibility to notify the Plan Administrator(s) or you forfeit t hat right. \par \par \par \ltrrow}\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\tx3150\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \ab\af0\afs23 \ltrch\fcs0 \b\fs23\insrsid5008419 LIFE INSURANCE}{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 \trowd \irow0\irowband0\lastrow \ltrrow \ts11\trgaph108\trleft-108\trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clshdng2000\cltxlrtb\clftsWidth3\clwWidth11016\clshdngraw2000 \cellx10908\row }\pard \ltrpar\qj \li0\ri0\widctlpar\tx3150\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 \par }\pard \ltrpar\qc \li0\ri0\widctlpar\tx3150\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 CONTINUATION OF STATE GROUP LIFE INSURANCE \par For a State Employee on a Leave of Absence or Seasonal Layoff \par \par }\pard \ltrpar\qj \li0\ri0\widctlpar\tx3150\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 If a participant in the State Group Life Insurance Pr ogram is on a leave of absence or seasonal layoff and wishes to continue State Group Life Insurance coverage, premiums must be paid for the period in which the participant is off the payroll. A 31 day lapse in premiums will terminate State Group Life Ins urance coverage. While on leave or seasonal layoff, premiums for employer-paid (State of {\*\xmlopen\xmlns2{\factoidname State}}{\*\xmlopen\xmlns2{\factoidname place}}fb88{\*\xmlclose}{\*\xmlclose} ) Basic coverage must be paid as well as any deductions for the additional Supplemental and/or Dependant coverage while the participant is off the payro ll. If coverage is not continuous, it will be necessary to pass a physical examination prior to beginning or reinstating Supplemental Coverage. \par \par }\pard \ltrpar\qc \li0\ri0\widctlpar\tx3150\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 CONVERSION OF STATE GROUP LIFE INSURANCE \par For a State Employee Who Terminates Employment \par \par }\pard \ltrpar\qj \li0\ri0\widctlpar\tx3150\tx5760\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 Coverage on any parti cipant or dependant will cease at the end of the last period for which premiums for that participant or dependant are paid to the fb88 State Retirement System, subject to a 31 day grace period. Therefore, if a terminated participant wishes to continue c overage, he must convert this coverage with }{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid9851705 the applicable}{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 }{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid9851705 l}{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 ife }{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid9851705 i}{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 nsurance }{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid9851705 c}{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 ompany}{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid9851705 (contact the fb88 Public Employees Retirement System for information)}{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 . Conversion will be allowed if application is made and the first premium paid within 31 days after the insurance coverage has terminated. Coverage will be converted to a private policy. \par \par If you have any questions concerning State Group Life Insurance, contact the fb88 }{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid9851705 Public Employees}{\rtlch\fcs1 \af0\afs23 \ltrch\fcs0 \fs23\insrsid5008419 Retirement System at 512\_3100 or 1\_ 800\_451-9800. \par }}