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Get Hc 5 2017 Form

393-21). 5. The coverage exemption/waiver previously indicated in items 2, 3 or 4 is no longer applicable; you are therefore required to provide me health care coverage (Section 393-18). Requested effective date of coverage: . Print employee name Employee signature Address Phone no. Date Call (808) 586-9188 with any questions about this form. Auxiliary aids and services are available upon request. Please call: (808) 586-9188; TTY (808) 586-8844; TTY neighbor islands (888.

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