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Emblemhealth dependent student certification form

Dependent student certification form 2025

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The document is a Dependent Student Certification Form from the Sergeants Benevolent Association, intended for members to certify their dependent's eligibility for health and welfare benefits. It requires member and student information, confirmation of the student's status as a full-time, unmarried student aged 19 or older, and validation from the educational institution's registrar. The form emphasizes the importance of notifying the SBA of any changes in dependent status.

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