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Get CO SG 01 2013-2024

Garettes Chewing Tobacco Pipe/Cigars Yes No Frequency Cigarettes Chewing Tobacco Pipe/Cigars Yes No Duration Cigarettes Chewing Tobacco Pipe/Cigars Cigarettes Chewing Tobacco Pipe/Cigars EMPLOYEE/DEPENDENT WAIVER OF COVERAGE Complete this section ONLY if you are not enrolling yourself or your spouse/partner or dependents. Waiver must be completed for all of your dependents to be eligible for enrollment on this plan in the event of changing circumstances. I understand that I am eligible t.

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