Es 935 form maryland 2025

1. Click ‘Get Form’ to open the es 935 form in our editor.
2. Begin by indicating your desire to continue coverage under the Employee Benefit Plan by selecting 'YES' or 'NO'. If you select 'YES', remember to attach a new application.
3. Fill in the effective date of continuation coverage and indicate whether your first payment is enclosed. Note that without this payment, access to health care coverage will be delayed.
4. Select the qualifying event from the options provided: Termination of Employment, Death, or Divorce.
5. Choose the type of insurance selected (Health, Dental, Vision) and note that additional lines of insurance can only be added during Open Enrollment.
6. Specify the type of coverage selected: Individual, Husband/Wife, Parent/Child, or Family. Remember that dependents may not be added until Open Enrollment unless there is a change in family status.
7. Sign and date the form, print your name, and provide your Social Security Number. A witness signature is also required.
8. For employer completion, ensure that the continuation coverage end date and billing details are filled out accurately.

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