Death of covered employee. Divorce or legal separation of covered employee. Covered employee becomes entitled to Medicare benefits.
Dependent child ceases to be a dependent under definition of employer's plan.
Please check the Plan number you wish to choose. No Coverage Elected 2. Your first payment must be received within 45 days of the date you sign this election form. You have 60 days from the date of this notice to notify us of your dependent's election. All subsequent payments are due on the 1st of the month covered.