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Get Daemen College Guardian Enrollment Form 2006-2022

Signature GG-013374D 3/06 Date MM DD YYYY Refusal of Insurance If the plan requires contributions and I have refused the insurance I understand that if I request coverage for myself and/or my eligible dependents at a later date I will be considered a late entrant and my dental benefits will be limited for specific periods of time. However I and/or my dependents will not be subject to late entrant penalties if dental coverage under another plan is.

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