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Her (Explain): SIC Code (required): Sole Proprietorship Zip: Date Business Established: Public Agency Type of Business: Tax ID #: Contact Name: Title: E-mail: Phone: What is your communication preference? Mail E-mail Fax Requested Effective Date: Fax: Group Eligibility Information Total # of Employees: Total # of Eligible Employees: Prior Dental Carrier: Dental Cancel Date: Is the waiting period waived for initial enrollment? Yes No Eligibility begins on the first of the mon.
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