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Legal First Name Middle Name Last Name and suffix if applicable 2. Mailing Address Street Route P. O. GROUP INFORMATION TO BE COMPLETED BY GROUP ADMINISTRATOR Group Number Effective Date Subgroup Class IDAHO UNIVERSAL GROUP APPLICATION FOR ENROLLMENT OUTSIDE OF THE IDAHO EXCHANGE Please type or print legibly in black ink and complete all applicable sections. Type of enrollment HEALTH DENTAL VISION Self Only Self and spouse Self spouse dependents Self one dependent Self two or more dependents...
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