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HIGHMARK BLUE SHIELD ENROLLMENT APPLICATION Employee must complete items 1 through 13 and sign. Do not complete shaded areas at bottom of form. E M P L O Y I N F R A T P. I authorize any payroll deductions required for the coverage and recognize that I must formally enroll my dependents on this form or they will not be covered. Authorized Employer Signature Date Employee Signature To be completed by Account/Administrator only Group Number 6206 F .

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