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CITY OF EUGENE HEALTH INSURANCE CONTINUATION INFORMATION <br /> NOTICE OF QUALIFYING EVENT: TERMINATION OF EMPLOYMENT <br /> Terminating employees and their dependents are eligible for continuation of health insurance benefits under <br /> federal or state law. It is important that you complete the following information whether or not you <br /> <br /> j intend to continue your health insurance coverage. Return this form to your supervisor or office manager <br /> with the attached Notice of Intent Form. <br /> <br /> i <br /> Employee Name Date of Birth <br /> <br /> i <br /> i <br /> Address <br /> City State Zip Code <br /> <br /> i <br /> <br /> I <br /> <br /> ~ Social Security # Home Telephone <br /> Pay Unit: <br /> ? AFSCME ? EPEA ?Non-Represented ? IAFF ? IATSE ? Other <br /> List of Covered Dependents: <br /> Name Birthdate Social Security # Relationship to Employee <br /> Address of Dependents (if different than above) <br /> Health insurance coverage is currently provided by (check one): <br /> ? Under the City Plan administered by ODS Health Plans (medical/dental/vision) <br /> O Under PacificSource with City Plan Dental/Vision Coverage <br /> i <br /> Do you have a Health Care (Medical) Flexible Spending Account? ? Yes ? No <br /> Do you want to continue access to your Employee Assistance Program (EAP)? ? Yes 0 No <br /> For HRRS use: COBRA ? RETIREE ? <br /> Qualifying Event: <br /> Qualifying Event Date: Coverage End Date: <br /> HRRS Staff Date <br /> <br />