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Arlington Texas Declaración jurada de no cobertura por otro plan de salud grupal - Affidavit of No Coverage by Another Group Health Plan

Category:
Empleo - Coronavirus - COVID-19 - Autorización
State:
Multi-State
City:
Arlington
Control #:
US-321EM
Format:
Word
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Description

El empleado mencionado en esta declaración jurada da fe de que no está cubierto por ningún otro plan de salud grupal. Para su conveniencia, debajo del texto en español le brindamos la versión completa de este formulario en inglés. For your convenience, the complete English version of this form is attached below the Spanish version.

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Arlington Texas Declaración jurada de no cobertura por otro plan de salud grupal
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