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Fax to 1 (866) 303-5117-2025

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The document is an Application for Enrollment/Change form from Regence BlueShield of Idaho, intended for self-insured groups with 100 or more employees. It outlines the process for new enrollment, changes, cancellations, and COBRA continuation coverage. The form requires detailed demographic information about the employee and their dependents, as well as prior health coverage details. It includes sections for plan selection, dependent enrollment, child custody information, and applicant signature to confirm understanding of terms and conditions.

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