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[DOC File]EyeMed Enroll Form - HSAG
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EMPLOYEE INFORMATION A: Add (enroll) T: Terminate C: Change (change of name, address or phone) (ADD (TERM (CHG. Sex ( M ( F Member ID. Last Name (Employee or subscriber) First Name. M.I. Date of Birth. Social Security Number. Home Street Address. City/State/Zip. Home Phone ( ) FAMILY INFORMATION (Only those eligible may be enrolled.) A: Add ...
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[DOC File]PHS 398 (Rev. 08/12), Inclusion Enrollment Report
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Program Director/Principal Investigator (Last, First, Middle): Inclusion Enrollment Report This report format should NOT be used for data collection from study participants. Study Title: Total Enrollment: Protocol Number: Grant Number: PART A. TOTAL ENROLLMENT REPORT: Number of Subjects Enrolled to Date (Cumulative) by Ethnicity and Race Ethnic Category Females …
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[DOC File]814-11 Enroll New Customer Municipal
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Confirm Auto-Enroll New Customer 814-AC . or. Confirm Auto-Enroll With Data Change 814-AD - to the Distribution Company. The 814-AC transaction should be used to confirm receipt and acceptance of the Auto-Enroll New Customer 814-AE when all …
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[DOC File]Model Language for Notice of Opportunity to Enroll
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Model Language for Notice of Opportunity to Enroll . in connection with Extension of Dependent Coverage to Age 26. The interim final regulations extending dependent coverage to age 26 provide transitional relief for a child whose coverage ended, or who was denied coverage (or was not eligible for coverage) under a group health plan or health insurance coverage because, …
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[DOC File]Fact Sheet on Automatic Enrollment in 401(k) Plans
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IN EMPLOYER-SPONSORED RETIREMENT SAVINGS PLANS . July 18, 2000 “Also, in an effort to encourage more workers to enroll in the 401(k)s that are already available to them, we have made it clear that employers can automatically enroll workers in the 401(k) plan unless the workers themselves choose to opt out . . . .
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[DOCX File]Family Care Program - Enrollment
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After you sign this form, you can choose not to enroll. Enrollment in Family Care is voluntary, and you may disenroll at any time. Changes in your health or financial situation may affect your eligibility for this program. If such changes occur, talk with your managed care organization (MCO) care manager or Tribal case manager, if applicable. ...
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