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WAIVER APPLICATION INSTRUCTIONS
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Please complete sections 2, 8, and 9.
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In section 8 please indicate the reason for declining coverage
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Please print when completed to sign and date and remit back to your employer.
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WAIVER APPLICATION INSTRUCTIONS
Please complete sections 2, 8, and 9.
In section 8 please indicate the reason for declining coverage
Please print when completed to sign and date and remit back to your employer.