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Get WI ET-4307 2020

F.wi.gov Complete this form to provide your Medicare information to ETF. You and/or your insured dependents must be enrolled for both portions of Medicare (Hospital Part A and Medical Part B), when first eligible. If not enrolled, you will be liable for the claims Medicare would have paid. All Persons Insured Under Your Group Health Insurance Policy Complete this information for all persons on your group health insurance policy. Include everyone on your plan, including yourself. See page 2 for.

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