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Get Group Master Application - Simmons Benefit Group

Sing and activation of your group. If additional space is needed please attach a separate sheet of paper. NEW/RENEWAL COVERAGE FOR GROUPS OF 2-99 Requested Effective Date SECTION 1 - GROUP INFORMATION Group's Legal Name Company Structure Sole Proprietorship Partnership Doing Business As (DBA) Location of Business Headquarters Legal DBA Name to be used by Regence Employer Federal (EIN) and State (if applicable) Tax ID Numbers SIC Code and Industry Description Name and Title of President,.

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