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THIS INFORMATION MUST BE COMPLETED (even if your WAIVING coverage) – Note: YOU MUST EITHER ACCEPT OR WAIVE COVERAGE by completing and digitally signing this form, even if you do not want coverage. Incomplete information will delay delivery of ID cards and processing of claims. Are YOU Selecting Limited Benefit Plan 1 Coverage offered by your employer forYourself?

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ACCEPT OR WAIVE COVERAGE

OR

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