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Employee Benefit Trust 1205 Wind ham Parkway Romeoville, IL 60446 800.807.9460 / 630.378.3005 fax STATEMENT OF CHANGE OF ACTIVE EMPLOYMENT APPLIES TO ANY MEDICAL/DENTAL AND/OR VISION COVERAGES PART
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Provide any supporting documentation if required. This may include copies of legal documents, identification, or other relevant paperwork. Make sure to attach these documents securely to the form.
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Sign and date the statement of change of form. Failure to sign the form may result in it being rejected or delayed.
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