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Blank enrollment forms 2025

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The document is an Enrollment/Change Form for health insurance provided by the Vermont Office, intended for employers to complete on behalf of employees. It includes sections for employee information, action requested (enroll, change, cancel), coverage options, and family member details. The form also requires a signature and includes an authorization statement regarding the provision of medical information.

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Versions	Form popularity	Fillable & printable
2010	4.8 Satisfied (120 Votes)

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Blank enrollment forms 2025

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