Regulation .10 Election Statement.

The form which the insured shall use to elect coverage under these regulations shall be in language substantially as indicated in this regulation:

To _____________________________________________________________________________________________

(name of employer)

I _____________________________________________________________________________ whose Social Security

(name of employee)

number is __________________________________have been terminated as an employee on _______________________.

(date of termination)

Before termination I was covered under the employer's group health insurance contract (check one)

____ for myself.

____ for myself and dependents.

I elect to have this coverage continue in force and I agree to pay the required premium.

Date of Application: __________________________________

Signature of Insured: _________________________________

Mailing Address: ___________________________________________________________________________________