Small Group Blues Enroll - Arkansas Blue Cross and Blue Shield

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ARKANSAS BLUE CROSS AND BLUE SHIELDSMALL GROUP BLUESENROLL GROUP ADMINISTRATOR’S MANUALSAMPLE PARTICIPANT UPDATE FORMCeridian National Service CenterPARTICIPATE UPDATE FORMIMPORTANT: NOTIFY CARRIER OF THIS CHANGE IMMEDIATELYTO:GROUP ADMINISTRATORGROUP NAMEGROUP ADDRESSRE:CONTINUANT NAMECONTINUANT ADDRESSACTION: i.e., CANCELLATION, TERMINATION, REINSTATEMENT, ELECTION AND REASONSoc Sec Number: 000-00-0000Relationship : EMPSex: MDate of Birth : 07/30/61Benefit Class : B02Reason for QE : TERMINATION OF EMPLOYMENTQE Date : 08/02/96Ben Term Date: 08/31/96Election Date: 09/04/96First Paid Date: 10/21/96*CovTypeCarrCodeCarrier NameOptionStatusGroup NumberMABC1ARKANSAS BLUE CROSS AND BLUE SHIELDA Indiv+2/Fam 024281001* Note: M=MedicalD=DentalV=VisionH=HearingP=PrescriptionO=OtherS=Same as ContinuantW=Sponsored DependentX=Class II DependentCeridian National Service Center 34125 US Hwy 19 N. Palm Harbor, FL 34684 (800) 488-8757Small Group BluesEnroll R 10/25/07 29
ARKANSAS BLUE CROSS AND BLUE SHIELDSMALL GROUP BLUESENROLL GROUP ADMINISTRATOR’S MANUALSection 10 - STATE OF ARKANSAS LAW GOVERNING CONTINUATION OFCOVERAGE BEYOND TERMINATIONGroups not eligible for COBRA may be subject to the State of Arkansas’ continuation ofcoverage law. In certain situations this Law allows the extension of coverage for up to120 days.A covered person whose employment terminates or dependency status changes shallhave the right to elect continuation of coverage under the Policy as outlined below. Inorder to be eligible for this option, the covered person must:• Have been continuously covered under the Policy for at least three (3) consecutivemonths prior to employment termination or change in dependency status; and• Make the election by notifying the Company in writing no later than 10 days after theemployment termination or change in dependency status.CONTINUATION SHALL TERMINATE ON THE EARLIEST OF:• One hundred twenty (120) days after the date the election is made;• The date the Covered Person fails to make any premium payments or thePolicyholder fails to pay the premium to the Company;• The date on which the Covered Person is or could be covered by Medicare;• The date on which the Covered Person is covered for similar benefits under anothergroup or individual Policy;• The date on which the Covered Person is eligible for similar benefits under anothergroup Plan;• The date on which similar benefits are provided for or available to the CoveredPerson under any state or federal law;• The date on which the policy terminates.Should you need additional information, please contact your Group ServiceRepresentative.Small Group BluesEnroll R 10/25/07 30
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Small Group Blues Enroll - Arkansas Blue Cross and Blue Shield

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