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Insurance action form - University of California, San Francisco

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The document is an 'Insurance Action Form' for UCSF Residents and Clinical Fellows, detailing the process for enrolling in, changing, or canceling health insurance plans. It includes sections for personal information, qualifying events, plan selection, and dependent information. The form requires signatures to confirm understanding of participation terms and conditions, including tax implications and eligibility requirements. Additionally, it outlines binding arbitration agreements for disputes with insurance providers and provides information on continuation privileges under COBRA.

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