Retiree COBRA Election Form
Please send this completed election form and the appropriate premium payment to:
Employees Retirement System of Texas Texas Employees Group Benefits Program (GBP)
Employees Retirement System of Texas Client & Benefit Operations P.O. Box 13207 Austin, Texas 78711-3207
Information provided to ERS is maintained for administration of your benefits. If you have questions about your information, or believe that information provided to ERS may be incorrect, please notify ERS.
Section A: Employee Data
National ID/SSN Employee Name: Last, First, MI
Section B: COBRA Applicant and Coverage Information
Name of COBRA Applicant (Last, First, MI)
National ID/SSN Date of Birth Gender
M F
Telephone Number
(
)
County
Mailing Address
City
State
ZIP Code
If you are applying for COBRA as a result of terminating employment, were you in a leave of absence status prior to terminating employment? Yes No N/A Are you a dependent electing continuation coverage under COBRA? Yes If yes, what is the date of the COBRA qualifying event? _____/_____/_____
Level of Medical Coverage: NO None MO Member (COBRA Applicant) Only MS Level of Dental Coverage*: NO None MO Member (COBRA Applicant) Only MS * May be elected without being enrolled in Medical coverage.
Indicate the coverage you want to continue under COBRA (The applicant must be included in each level of coverage.)
AM
Member & Spouse Dep. National ID/SSN (Required for 12 months or older)
Member & Spouse
PL E
No
MC MC Member & Child(ren) Date of Birth (mm-dd-yyyy)
Sp Sp Sp Sp Sp D D D D D S S S S S
Member & Child(ren)
MF MF
Member & Family Member & Family
Dependent Information (Complete Only if the COBRA Applicant is Covering Dependents)
Dependent’s Name (Last, First, MI) Relationship* Gender Health Dental
EX
O O O O O
M M M M M
F F F F F
Y Y Y Y Y
N N N N N
Y Y Y Y Y
N N N N N
*Relationship Code:
Sp - Spouse
D or S - Natural or adopted daughter or son
O - Other-than-natural or adopted child (must complete ERS GI 1.081)
Section C: Authorization and Certification (Please read carefully and sign)
I am requesting continuation coverage in the Texas Employees Group Benefits Program (GBP) under the provisions of COBRA. I understand that COBRA continuation coverage may be terminated if I: 1) become covered under any other employer sponsored group health plan that does not contain an exclusion or limitation relating to a pre-existing condition, 2) become entitled to Medicare, 3) submit any claims covered under this plan to any other group insurance plan, or 4) fail to pay my premiums in a timely manner. I will provide written notice to the address listed above if I have a change of address, eligibility, dependent or disability status. I authorize any provider to release any information about persons covered when such information is deemed necessary to determine eligibility or for the proper disposition of a claim or complaint. I have read and understand the COBRA Continuation Coverage Election Notification which accompanied this Election Form and agree that no representative may verbally modify or override benefits clearly presented in the COBRA Continuation Coverage Election Notification. I certify that the information above is true and correct to the best of my knowledge and am aware that any fraudulent statements on my part may be cause for expulsion from this program.
Signature:_____________________________________ Date:______________ Daytime Telephone Number:____________________
(Parent or legal guardian may sign for minor child)
Email Address:_________________________________________________
ERS GI 2.832 (R 04/2007)