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Ithin 10 calendar days after Medicare confirms your eligibility we ll confirm the effective date of your coverage. Are you covering a spouse or dependents under this employer or union plan If yes name of spouse Name of dependents N/A 4. Do you or your spouse work 2. If your employer provides retiree coverage are you the retiree If yes retirement date month/day/year If no name of retiree retirement date month/day/year 3. Today s Date Signature If you are the authorized representative you must...

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