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Get MI R0452C 2011

For dependents. See the instructions for details on eligible dependents and required proofs. If you or any of your dependents will be covered under another insurance plan, including Medicare, as of the effective date of this coverage, you must indicate that additional coverage below. Copy the Medicare information from the Medicare card for anyone you are covering. NAME (LAST, FIRST, MIDDLE) MEDICARE #/SOCIAL SECURITY # SEX DATE OF BIRTH M QUALIFYING EVENT: ADOPTION BIRTH MARRIAGE OTHER D.

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