ELECTION FORM FOR CONTINUATION OF BENEFITS (COBRA)
THE PENNSYLVANIA STATE UNIVERSITY
Employee Benefits Division
120 S. Burrowes Street
University Park, PA 16801

(814) 865-1473

Coverage may be continued under the following conditions:

Retirement, termination or layoff* - up to 18 months. Effective Date_______________

Spouse and /or child(ren) of deceased or divorced employee - up to 36 months. Date of death or divorce____________.

Dependent child reaching maximum age for coverage - up to 36 months. Date child attains the age of 19, ceases to be a full-time student or attains the age of 24 ______________.


Note:

*Individuals on layoff are eligible to maintain coverage for the first 120 calendar days of the layoff by payment of the regular contribution rates in effect prior to layoff. However, in no event will the continuation of coverage exceed a total of 18 months.

Other Insurance: Do you or your dependents have other coverage?___No __Yes

If yes, complete the following: Name and address of Insurance provider:________________
______________________________________________________________________

Name(s) of insured:__________________________Effective date:___________________

Rates will be adjusted each January 1. Check appropriate block(s) to indicate coverage(s) to be continued.

2005 Monthly premium rates are as follows.

Initial Premium $______________

Present Health Plan A     Penn State Choice
   HealthAmerica
(HMO)
Participant only

$640.79

    

$347.12

  

$246.41
Participant & Sp or Child $1281.61
Two or more individuals

$1473.85

    

$914.56

  

$648.99
                      Other HMO:_____________________   Other POS:_________________  
Participant only                    

*_______________________

  

*__________________
Two or more individuals                    

*_______________________

  

*__________________

              

* For rates for other HMO and POS plans call EmployeeBenefits, (814) 865-1473.

Dental       Dental
Enhanced 		   Vision        
Participant only

$24.37

    

$34.40

   Participant only

$4.00

      
Two or more individuals

$64.12

    

$87.84

   Two or more individuals

$12.02

      

* If you are enrolled in an HMO or Point of Serivce other than  HealthAmerica, contact the Employee Benefits Division for the correct rates.

Coverage is to be continued for:               Effective date of coverage ________
Self             Spouse           Child           Two or more children

Provide following information for those to be insured:

Name     Social Security Number     Date of Birth
_____________________________     _____________________     ______________________
_____________________________     _____________________     ______________________
_____________________________     _____________________     ______________________
_____________________________     _____________________     ______________________

READ CAREFULLY!!!

I elect to continue coverage for myself and/or my eligible dependents (if applicable) under The Pennsylvania State University healthcare plan. I understand that:

1. MONTHLY BILLS WILL NOT BE PROVIDED.

2. Premiums are due by the first of each month.

3. IF PAYMENT IS NOT MADE WITHIN 30 DAYS OF THE DUE DATE, COVERAGE WILL BE CANCELLED AND CANNOT BE REINSTATED.  NOTE THAT HEALTHCARE COMPANIES  MAY NOT VERIFY COVERAGE DURING THE GRACE PERIOD.

4. Checks should be made payable to The Pennsylvania State University and sent to:

Employee Benefits Division
Penn State University
120 South Burrowes Street
University Park, PA 16801
(814) 865-1473

5. Initial premium payments must be included with the application.

 

___________________________________           ______________________________________
Signature of Participant           Date
             
Address:____________________________           ______________________________________
___________________________________           Name of Employee
Phone:______________________________           ______________________________________
(Area Code) Number           Employee's ID Number

12/17/2004