Continuation Coverage (Cobra) Election Form

CONTINUATION OF COVERAGE (COBRA) ELECTION FORM

NATIONWIDE INSURANCE

DATE OF NOTICE: ______, 2008______

Agent or Employee Name: ______Agent Number: ______State #: ______

Address: ______

City, State, Zip: ______

QUALIFYING EVENT: ______

QUALIFYING EVENT DATE: ______/______/______COBRA EFFECTIVE DATE: _____/_____/______

*IF YOU DO NOT RETURN THIS ELECTION FORM WITHIN 60 DAYS, YOU WILL

LOSE YOUR RIGHT TO ELECT CONTINUATION COVERAGE.

BE SURE TO SIGN AND DATE THIS FORM*

ELIGIBLE BENEFIT PROGRAMS

PLAN NAME:

Nationwide Career/Independent Contractor Agents’ Health Plan Number: _0.1202560 ______

Nationwide Inactive/Retired Agents’ Health Plan Number: _87,1202417______

I ELECT TO CONTINUE THE COVERAGES INDICATED BELOW:

AGENT or EMPLOYEE

CCN PPO/$______Medicare Supplement

With Drug

WithOut Drug

SPOUSE

CCN PPO/$ ______Medicare Supplement

With Drug

WithOut Drug

CHILD(REN) please list below

CCN PPO/$ ______Medicare Supplement

With Drug

WithOut Drug

Signature ______Date ______

Pg. 2

List below your dependents for who you wish to continue coverage.

Dependent Name Date of Birth Social Security # Relationship

1) ______

2) ______

3) ______

4) ______

5) ______

6) ______

Signature ______Date; ______