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By Fax 1 (866) 303-5117-2025

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The document is an Affidavit of Qualifying Incapacitated Dependent Eligibility form, which requires employees to provide information about their incapacitated dependents for health insurance coverage. It includes sections for the employee's and dependent's details, employment status, health insurance coverage, and a statement from the attending physician regarding the dependent's incapacity.

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