Regulation .10 Election Statement.

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 ____________________________ died on ____________________________________

(date od 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: _______________________________________________________________________________