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LOA Other Than Family and Medical Leave - Application for Continuation of Group Insurance


Before completing, please read document titled
"LOA: Continuation of Group Coverage While on Leave of Absence (LOA)
Other Than Family and Medical Leave"
and LOA Rates


Employee’s Name: _______________________________________________

Address: _______________________________________________________


Telephone Number: ______________________________________________

Social Security Number: __________________________________________

Campus: _______________________________________________________

Anticipated leave period: From ___________ To ___________

_______ Health Insurance

_______ Dental, Vision, Life

All benefits may be continued or just health insurance. If health insurance is not continued, dental, life, and vision care may be continued only as a package.

Signature: ____________________________ Date: __________________


Rev. 1/98