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Get 2013 Annual Enrollment Form

That information provided to ERS may be incorrect, please notify ERS. Return the completed form to your agency benefits coordinator. Section A: employee Data (For assistance, contact your benefits coordinator or ERS.) Last 4 digits of SSN Agency Name Dept ID/Agency Number Effective Date 09-01-2012 xxx-xxEmployee Name: First, MI, Last Phone Number o Home o Cell ( Mailing Address City o Check if New State E-Mail Address ) ZIP Code Eligibility County Important: Annual Enrollment pe.

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