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Signed at County State Writing Agent s Signature Date / / FL-72000 10/2013 Reorder FL-52000-SB 10/2013 Principal Enrollment Employee Signature Read and sign below. If my dependents or I have selected life or disability I authorize any third party to have information regarding myself. This includes any medical or non-medical information and to share any and all such information with Humana its reinsurer or its legal representatives and its affiliates. FOR NEW BUSINESS ONLY...
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