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E Policy No.: District Paid Insurance Coverage Please print clearly, and complete all questions. Form may be returned for completion of unanswered questions. 1. EMPLOYEE Name of employee: Address: City: State: Zip Code: Job Title: Class: Faculty/Teacher Phone No.: ( Education Support Professional Administration ) Secretarial/Clerical Date Employed: Other: Social Security No.: 2. INFORMATION Last day worked: Number of hours worked on last day: Status on d.

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