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00 16. 68 10. 58 22. 28 Relationship S pouse D ependent G randchild Sex Medical M F A R VSP Basic High Dependent s / Grandchild WAIVER OF HEALTH INSURANCE/OPT-OUT PLAN I understand that as an active employee if I waive health coverage and desire to participate in the plan at a later date I will only be able to enroll during open enrollment or if an approved qualifying event occurs and I enroll within 60 days of the qualifying event and provide proof of previous coverage. 00 160. 00 SSN...
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