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The document is an Employee Dental Enrollment and Change Form for the State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP). It outlines the process for employees to enroll in or change their dental coverage, including providing personal information, reasons for application, level of coverage, and dependent information. The form also includes instructions on required documentation for dependent eligibility and emphasizes the importance of accurate information to avoid penalties.

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