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Get Young Adult Option Form - View Website - New York State

Er the Young Adult Option, please complete this form and return it to the address listed above with full payment for the first month s premium. Please provide the necessary documentation to establish eligibility. Checks should be made payable to Employee Insurance Pending Account. If you are NOT enrolling during open enrollment, proof of loss of previous coverage is required. Please note: Election for coverage can be made by either the Parent Enrollee OR the eligible Young Adult. YOUNG.

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