Maryland Continuation Election Form PDF Details

Have you recently moved to Maryland and are looking for information on how to vote in the upcoming elections? Look no further, as this blog post will provide you with all the information you need about Maryland's continuation election forms. From what documents are needed in order to apply, who is eligible for these forms and where you can obtain them, this guide covers it all - so keep reading if you want answers!

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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This form will require specific data to be filled out, thus ensure you take some time to enter exactly what is required:

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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