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: ___________________________________________________________________________________