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Pplication promptly, please remember to: • Print all answers in black ink. Pencil will not be accepted. • Make sure you personally sign the application as the Primary Applicant. If your spouse or any dependent child(ren) age 18 or over is also applying for coverage, have him/her personally sign the appropriate signature line. Parent/guardian must sign if primary applicant is a minor. • If you are downgrading (decreasing benefits), you do not need to complete Part Two, Sections A and B. PA.

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