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Get CA FL-475 2003-2024

NT: EMPLOYER'S HEALTH INSURANCE RETURN 1. Name of parent employee: 2. Home address of absent parent employee: Not known 3. The employee has no insurance policies for health care, vision care, or dental care through this employment. 4. The employee has the following insurance policies covering health care, vision care, and dental care: Company Type of policy Policy No. Persons insured Date: (SIGNATURE OF EMPLOYER) (TYPE OR PRINT NAME OF EMPLOYER) Address: Telephone No.: 5. Return this c.

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