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Ation. PART ONE (Please PRINT IN INK) Fax: 803-264-0225 SECTION A - APPLICANT INFORMATION Requested Effective Date: / / P.O. Box 100118, Columbia, SC 29202-3118 www.SouthCarolinaBlues.com As of the requested effective date, will you be a resident of South Carolina? (Only South Carolina residents are eligible for coverage.) (Effective dates must be either the 1st or the 15th of the month.) First Name: / / Social Security Number: Telephone Number: Home/Cell: ( - No Are you a United Sta.

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