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Get Nationwide NRI-0118AO-0607

Ocial Security Number Address City, State, & Zip Code Certification as to Insurance Company Information/ Eligibility Phone Number I am an Eligible Retired Public Safety Officer of ___________________________________________ (Entity Name). I am entitled pursuant to Internal Revenue Code Section 402 to elect to have a portion of my qualified health and/or long-term care insurance premiums deducted on a pre-tax basis from my Defined Contribution Plan and paid directly to my Insurance Company. .

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