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INTERIM COVERAGE OF
HOSPITALIZATION-LIFE INSURANCE FORM
Name:____________________________________ Social Security No.:__________________
Address:______________________________________________________________________
Mailing Address City State Zip Code
¨ I elect to continue hospitalization-life insurance coverage as indicated below:
Coverage: ¨ Hospitalization ¨ Life Insurance
Period: From:_____________________ To:__________________
Payment Schedule:**
Month of Coverage Payment Due Amount
__________________________ ______________________ __________________
__________________________ ______________________ __________________
__________________________ ______________________ __________________
__________________________ ______________________ __________________
__________________________ ______________________ __________________
__________________________ ______________________ __________________
**Note: Advanced payment of premiums can be paid at any time.
The time of payment may be extended one or more times and from time to time without notice to or further assent of any of the parties hereto who shall remain bound, notwithstanding such extension(s).
In the event of non-payment of all amounts due on the above dates, I understand that my coverage may be cancelled by the College.
________________________________ ___________________________
Signature of Employee Date
¨ I do not elect to continue hospitalization-life insurance coverage during the period: From:_____________________ To:__________________
I understand that I and/or my family will be required to qualify for insurance coverage if I decide to renew my insurance.
___________________________________ ___________________________
Signature of Employee Date
Form 2600/001 (12/05)
BA-2600.1A
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