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Complete this form and return it to BWC to meet these requirements. •. Include a copy of the insurance policy as proof of coverage from the other state.Notice of Election to Obtain Coverage from Other States for Employees Working Outside of Ohio Please read this information before completing the form. Under federal law, you have 60 days after the date of this notice to decide whether you want to elect COBRA continuation coverage under the Plan. Plan administrators that receive notice of a qualifying event must notify qualified beneficiaries of their right to elect COBRA coverage. ENROLLEE INFORMATION: Blocks 1-15 must be completed for all transactions, including termination of coverage. Blocks 1-19: ENROLLEE INFORMATION: Must be completed for all transactions, including a refusal of coverage. Such as private, state, or Medicaid, check the box and complete item 22. Registering online is easy, safe, and secure. Pennsylvania law, you have thirty (30) days after the date of this notice to decide whether you want to elect continuation coverage.