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Get Fort Dearborn Life Employment Application

Ion on pages 1 and 2. If your group has 50 or fewer enrollees, please complete the Medical Questionnaire on page 3 (see the directions page for details). Note that your employer may ask you to complete the Medical Questionnaire even if your group has more than 50 enrollees. If you are declining any coverage being offered to you through Blue Cross or Fort Dearborn Life, please complete and sign the Waiver of Coverage form on page 4. Thank you. *Fort Dearborn Life is a separate company that.

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