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4. Employer must complete if Section VII is answered – Number of employees in group: __________. 3. Please return this form to your employer. 2. Complete all appropriate items, sign and date. I. EMPLOYER INFORMATION – To be completed by the employer Employer / Group Administrator Effective Date Requested / / Group Number Date of Birth / Sex Male II. ENROLLEE Social Security Number Last Name / First Name Date of Hire / / Occupation Residence Address (Number and Street) Home Pho.

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