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1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your full name in the designated fields for last, first, and middle initial.
3. Fill in your address details, including street, apartment number (if applicable), city, state, and zip code.
4. Provide your contact numbers: home, work (with extension), and cell phone.
5. Indicate your employment status by selecting from options such as full-time, part-time, student, retired, or not employed.
6. Complete the insurance information section by entering details about your primary and secondary insurance providers.
7. For emergency contacts, list two individuals along with their relationship to you and their phone numbers.
8. Review all entered information for accuracy before signing at the bottom of the form.

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