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Group Medical Direct Claim Form Aldine Independent School District Insured and/or Administered by Connecticut General Life Insurance Company CHINA Healthcare MAIL THIS FORM TO: CHINA Healthcare Service
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EMPLOYEE'S RESPONSIBILITY FOR COVERING Employees C. EMPLOYER'S OR HEALTHCARE GUARD'S NAME and CITY ADDRESS (Street, City, State, Zip)--NOTE--IN ADDITION--DATED MARCH 31, 2007, F. EMPLOYER'S CERTIFICATE OF INSURANCE or OTHER STATUTORY PROOF OF INSURANCE IN EFFECT WHEN EMPLOYER IS ON BOARD OF TRUSTEE AND/OR INSURER FOR EMPLOYEES G. EMPLOYEE'S CERTIFICATE OF INSURANCE or OTHER STATUTORY PROOF OF INSURANCE IN EFFECT WHEN EMPLOYER IS ON BOARD OF TRUSTEE AND/OR INSURER FOR EMPLOYEES H. EMPLOYER'S E-MAIL ADDRESS (or POST-TAX ADDRESS) I. EFT ID# (IF PRESCRIBED) and TYPE OF EMPLOYEE--INCLUDING ANTIQUES--and/or METHOD OF PAYMENT J. EMPLOYER'S REASON FOR INSURING EMPLOYEE with Employer's CERTIFICATE OR OTHER STATUTORY PROOF OF INSURANCE K. EMPLOYER'S TELEPHONE NUMBER (IF PRESCRIBED) L. EMPLOYER'S PHONE NUMBER (if PRESCRIBED) M. EMPLOYER'S E-MAIL ADDRESS (if PRESCRIBED) N. EMPLOYER'S E-MAIL ADDRESS (if PRESCRIBED) O. EMPLOYER'S REASON FOR INDIVIDUAL CO-PAYMENTS P. EMPLOYER'S CERTIFICATE OF INSURANCE if PRESCRIBED Q. EMPLOYER'S CERTIFICATE OF INSURANCE if PRESCRIBED R. EMPLOYER'S RESPONSIBILITY TO THE ADMINISTRATIVE GROUP REASON FOR EMPLOYEE'S INSURANCE S. EMPLOYER'S RESPONSIBILITY TO THE ADMINISTRATIVE GROUP REASON FOR EMPLOYEE'S INSURANCE T.
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