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Get Portability Application - Ima

Enrollment form, make a copy for your records and then give this enrollment form to the employee or employee's dependents whose coverage is terminating on or before the date of group coverage termination. If you have any questions please call 1-877-320-0484. Important Note: The employee must submit the completed enrollment form and first quarterly premium to the address listed below within 31 days from the date of group coverage termination or 15 days from the employers signature date on this f.

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