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Get NE UNI_APP2

Average Hours Worked per Week_______ Salary/Wage $__________ Employment Status: Marital Status: Married Single Divorced Legally Separated Full-Time Part-Time Retired COBRA Widowed WAIVER OF COVERAGE I decline coverage for: Declining coverage due to existence of other coverage: Medical Self Spouse's Employer's Plan Dental Spouse Covered by Medicare Life Children COBRA from prior employer Vision Family I (we) have no other coverage at this time Disability Disability Individual Plan VA .

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