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AUSTIN INDEPENDENT SCHOOL DISTRICT Certification of Qualifying Individual Coverage SECTION I: Employee: Last Name Address: First Name MI SECTION II: Qualifying Individual Indicate the name of the
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This document is a certification form for qualifying individual coverage under Austin Independent School District.
Employees of Austin Independent School District who are enrolled in individual health coverage are required to file this certification form.
The form must be completed with accurate information about the individual health coverage, and signed by the employee.
The purpose of this form is to certify that the employee has qualifying individual health coverage.
The form requires information about the type of individual health coverage, policy number, and effective dates.
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