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For GPL Head Office Use Only GPL Certificate Number APPLICATION FOR GROUP COVERAGE Please print clearly and complete both sides of this form, in INK. Section 1 is to be completed by the plan administrator
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Sections 2 through cover information related to employee demographics and personal details.
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The purpose of sections 2 through is to gather data on the employees for reporting and compliance purposes.
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Information such as employee name, date of birth, social security number, and citizenship status must be reported on sections 2 through.
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