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Get Independent Health APP-1000 2011-2024

Ction — Employer Information to be completed by Group Benefits Administrator Individual/Conversion Group Group # HRA Subgroup # FSA Parking/Transit Plan Number Effective Date MM / D D / Y Y Y Y Employer Name Chamber or Association Name (if applicable) 2. Reason for Request/Qualifying Event Add: ■ Adoption ■ Change in Employment Status ■ COBRA (indicate reason below) ■ Involuntary Loss of Coverage ■ Legal Guardianship ■ Marriage/Domestic Partner Date of Qualifying Event.

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