The form which a qualified secondary beneficiary shall use to elect coverage under these regulations shall be in language substantially as indicated in this regulation: To _____________________________________________________________________________________________ (name of employer) The employee ____________________________________________________________________________________ (name of employee) Whose Social Security number was ____________________________ died on ____________________________________ (date od death) This is to advise that _______________________________________________________________________________ ____________________________________________________________________________________________ (name or names of qualified secondary beneficiaries) who were covered as qualified dependents of the employee under the employer's group health insurance contract elect(s) to continue to be covered under that contract beginning with the date of death. Date of Application: ________________________________ Signature of Qualified Secondary Beneficiary: _____________________________________________________________________________ Mailing Address of Secondary Beneficiary: _______________________________________________________________________________

Authority: Insurance Article, §§2-109, 14-124(b), 15-407—15-409, and 15-412; Health-General Article, §19-703; Annotated Code of Maryland

Effective date: December 14, 1987 (14:25 Md. R. 2659)

Chapter recodified from COMAR 09.30.83 to COMAR 31.11.03 effective September 7, 1998 (25:18 Md. R. 1439)

Regulation .08 repealed effective June 22, 2015 (42:12 Md. R. 764)