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NEBRASKA UNIFORM GROUP HEALTH APPLICATION EMPLOYER DATA Employer Group Number Street Address Phone City State ZIP Fax Employee Name Social Security Disabled Y Home Address Work Phone DOB N Medicare Enrolled Y Home Phone Height N Sex M F Email Job Title Date of Hire Primary Care Physician Average Hours Worked per Week Marital Status Married Employment Status Full-Time Salary/Wage Part-Time Retired COBRA Single Divorced Legally Separated Wid....
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