July 11,1995 BA-2600.1 BA-2600.1A July 11, 1995 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:** ...
Allowed
Microsoft Office Word (.doc, .dot) - application/msword