Affidavit Group Form - Affidavit of No Coverage by Another Group Health Plan

State:
Multi-State
Control #:
US-321EM
Format:
Word
Instant download

Description Plan Documento Descalificado

El empleado mencionado en esta declaraciĆ³n jurada da fe de que no estĆ” cubierto por ningĆŗn otro plan de salud grupal. Para su conveniencia, debajo del texto en espaƱol le brindamos la versiĆ³n completa de este formulario en inglĆ©s. For your convenience, the complete English version of this form is attached below the Spanish version.

How to fill out Affidavit Group Form?

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DeclaraciĆ³n Jurada