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■ <br />ELECTION <br />If you decide to continue coverage, please so indicate below and return this form <br />to the office shown below within 60 days after the later of: (a) the date coverage <br />would otherwise end, or (b) the date of this notice. IF THIS FORM IS NOT RECEIVED <br />WITHIN THE 60 DAY PERIOD MENTIONED ABOVE, YOU WILL NOT RECEIVE 00NTINUED <br />BENEFITS. <br />PLEASE CHECK ONE OF THE FOLLOWING BOXES, SIGN AND DATE <br />❑ I do not want to continue coverage <br />under the health plan. <br />I want to continue coverage as <br />follows: <br />❑ For myself only <br />❑ For m_v-.elf and my dependents <br />listed on page 2 <br />❑ For my dependents listed on <br />page 2 <br />fate <br />Qualified Beneficiary Qualified Beneficiary Telephone <br />Birth Lute Social Security Number <br />Home Address City and State Zip <br />DEPENDENIS <br />Last Name First Name & Middle Initial Date of Birth Relation <br />Current dependents may be provided continuation only if they were covered under <br />the group health plan on the day before the qualifying event. However, any person <br />who acquires a new dependent (spouse, newborn or adopted child, etc.) during a <br />period of continued coverage may under certain circumstances elect coverage for <br />that dependent contact the City's payroll clerk to determine eligibility. <br />Page 2 <br />Form COBRA-2 <br />