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R MEDICAL AND DENTAL COVERAGE: While the Federal Patient Protection and Affordable Care Act mandates coverage of dependent children up to age 26, your plan may allow coverage beyond age 26 for medical plans and some dental plans. Some exceptions apply. Please refer to your plan documents or contact your benefits administrator. 1. Employee Name (Last, First, M.I.) Sex (M/F) Social Security Number Birthdate (MM/DD/YYYY) Height (ft, in) Weight (lbs) Coverage Election Medical Dental Life/Disability.

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