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Get Opt Out & Opt In Election Certificate - Uic

Me employees, retirees/annuitants and survivors may elect not to participate in the health, dental and vision coverage of the State of Illinois Group Insurance Program (Program). Enrolled dependents of individuals electing to opt out will be terminated on the same date as the Member. Member Name: Member SSN: I fully understand and certify the following: 1. The election to opt out of the Program is entirely voluntary. If I elect to.

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