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Extension: Department / MS#: Employment Status: Faculty (FAC) Postdoctoral Fellow (FAC) (Please check one) Non-Exempt (NEX) Non-Exempt Union (UNE) Action Requested: Change of Benefit Coverage Exempt (EXS) Library Exempt Union (EXS) Police Services Union (PSU) Cancellation of Benefit(s) Effective Date: , 20 Qualifying Event for Change or Cancellation Please check the Qualifying Event for your.

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