Philadelphia Pennsylvania Affidavit of No Coverage by Another Group Health Plan

State:
Multi-State
County:
Philadelphia
Control #:
US-321EM
Format:
Word; 
Rich Text
Instant download

Description

The employee named in this affidavit attests to the fact that he or she is not covered by any other group health plan.

How to fill out Philadelphia Pennsylvania Affidavit Of No Coverage By Another Group Health Plan?

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Philadelphia Pennsylvania Affidavit of No Coverage by Another Group Health Plan