City of New York
Office of Labor Relations
Employee Benefits Program
40 Rector St, NYC, NY 10006

ATTN: Honorable James F. Hanley, Commissioner
Dorothy A. Wolfe, Director                                                          Reference: NY State Chapter Law 436

Dear Sir or Madam:

I hereby notify you that I wish to participate in the health insurance program afforded to a surviving spouse of a deceased retired New York City Firefighter (member FDNY) as provided under New York State Chapter Law 436, paragraph (ii).

I understand this Law allows me to continue in the existing insurance coverage that was provided to my spouse; that I may continue this coverage for the rest of my life and that I will pay 102% of the COBRA premium.

Please enroll me in the Chapter Law 436 continuation of permanent health Insurance coverage.

Your confirmation to me in writing that I have been enrolled in the program will be greatly appreciated.

Very Truly Yours,

Signature______________________________ Date______________________________

Name (Print)___________________________ Address ____________________________

Date of Birth ___________________________ Social Security No.________________________

Spouse Name (Deceased) (Print)____________________________________

Date of Birth ___________ Date of Death__________ Social Security No.____________________