1. INTERIM COVERAGE OF
    2. HOSPITALIZATION-LIFE INSURANCE FORM
    3. Payment Schedule:**

 


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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