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Retiree Medical Coverage Election Form for Dependent Children Electing/Declining Dependent Coverage Please select ONE I ELECT as of to have the IBEW Local 701 Health and Welfare Coverage for my dependent child ren listed below who is/are under the age of 26. SEE WELFARE SUMMARY PLAN DESCRIPTION FOR THE DEFINITION OF AN ELIGIBLE DEPENDENT. Signature Date Dependents you would like to cover under the age of 26 Fill out Special Enrollment Form for each dependent if he/she is over age 19 SSN DOB /...
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