Maryland Continuation Election Form PDF Details

In Maryland, individuals facing certain life events that result in the loss of employment-related health benefits have the option to continue their coverage through a process known as the Maryland Continuation Election. This crucial form serves as a lifeline, allowing employees and their families to maintain health, dental, and vision insurance during transitions. By completing the Maryland Continination Election Form, an individual signifies their intention to keep their coverage active under the specific plan provided by their employer. It's a declaration that necessitates a detailed understanding of one's rights and responsibilities, underscored by the requirement to have thoroughly reviewed the Maryland Continuation Coverage Notice and any accompanying documentation. The form encompasses several key decisions, including the type of insurance and coverage selected, which is especially important since changes, such as adding new lines of insurance or dependents, are restricted to periods of open enrollment or qualified family status changes. Aside from marking a choice to proceed with continuation coverage, the form captures essential details such as the effective date, whether the first payment has been made (a prerequisite for activating coverage), and the nature of the qualifying event leading to the loss of coverage, such as termination of employment, death, or divorce. All these elements are critical, not just for the individual electing to continue their benefits but also for employers who play a role in facilitating this continuation and need to be informed about billing directives. The process embodies a structured method to ensure that individuals do not find themselves without necessary health benefits during significant life changes, making understanding and correctly completing the Maryland Continuation Election Form paramount.

QuestionAnswer
Form NameMaryland Continuation Election Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesget the es 935 maryland form, maryland es 935, maryland es 935 unemployment, es 935 md

Form Preview Example

MARYLAND CONTINUATION ELECTION FORM

I wish to continue coverage under the <Name of Company> Employee Benefit Plan. I understand that this election is subject to the Plan. I have read and understand the MD Continuation Coverage Notice and the letter that accompanied this election form and both MD Continuation rights and limitations on those rights.

YES NO

IF YES, PLEASE ATTACH A NEW APPLICATION

Effective date of continuation coverage:

 

First payment is enclosed:

YES

NO

 

(If first payment is not enclosed, you will not be able to access health care coverage until payment is received.)

Qualifying Event:

Termination of Employment

Death

Divorce

Type of Insurance Selected:

Health

Dental Vision

(May not add lines of Insurance until Open Enrollment.)

Type of Coverage Selected:

Individual Husband/Wife Parent/Child

Family

 

 

 

 

 

 

(Dependents may not be added until Open Enrollment unless a

 

 

 

 

 

 

change in family status occurs.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Print Name

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Witness

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For Employer to complete:

Continuation coverage end date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bill to Company:

 

 

 

 

Bill to Qualified Beneficiary:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Billing address

 

 

 

 

 

 

 

 

City

State

Zip

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1. It's very important to complete the get the es 935 form maryland correctly, so take care while filling out the parts that contain these blanks:

es 935 md completion process shown (part 1)

2. Right after performing the last part, go to the subsequent stage and complete the essential particulars in all these blank fields - Dependents may not be added until, Signature, Print Name, Date, Social Security Number, Signature of Witness, For Employer to complete, Continuation coverage end date, Bill to Company, Bill to Qualified Beneficiary, Billing address, City, State, and Zip.

The way to fill out es 935 md portion 2

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