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Check One: New Application for Coverage Change Authorization Waiver of Coverage (complete Section (4) ONLY) Enrollment×Change Formation Section 1 Action Add EMPLOYEE INFORMATION: (Please Type or
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Check one new application is a form that individuals or entities must fill out to apply for a particular program or benefit.
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Individuals or entities who wish to apply for the program or benefit are required to file check one new application.
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Applicants must report personal information, contact details, financial information, and any other details required to assess eligibility.
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