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city state zip Who can we contact about employee health coverage at this job Contact Name Phone Email address oYes oNo 1. Does your company offer health insurance If no skip to section D. Sign and return the form* 2. Is your health insurance a state employee benefit plan 4. Is the employee eligible to enroll in any insurance plan offered If no please explain If yes when is/was the employee eligible to enroll mm/dd/yy If yes name s of person s enrolled 6. Has this employee or any family member d ...

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