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Insurance Portability and Accountability Act HIPAA. The Insurance Companies are subject to the Gramm-Leach-Bliley act and state privacy laws. Insured Beneficiary Percentage Date of Birth Relationship Life ACCEPTANCE/DECLINATION I accept the insurance coverages elected above. EMPLOYER USE MANDATORY DATA NEEDED In order to process this application the employer must complete this information. Lesley University EMPLOYER CLASS LOCATION/PAYCODE DATE OF HIRE ANNUAL SALARY VERIFIED BY REASON FOR...
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