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The document is a Selectable Option Enrollment Form for employees to enroll in medical, dental, vision, and life insurance coverage offered by their employer. It includes sections for employee and eligible family member information, coverage selection, waiver of coverage, and necessary signatures. The form outlines the process for selecting primary care physicians, provides instructions for completing the form, and emphasizes the importance of accurate information to avoid denial of benefits.

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Versions	Form popularity	Fillable & printable
2010	4.8 Satisfied (135 Votes)

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