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Missoula, MT 59806 This form may also be returned by fax toll-free (866) 201-0522 or emailed to cobinfo@askallegiance.com. Please be sure to include your full name and group number. Participant Name_________________________________ Group Number: _______________________ Group Name:________________________ Do you have any health coverage (includes Medicare coverage) other than that provided by the group referenced above? ____Yes ____No If yes, name of other insurance: ____________________________.

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