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Illinois 2017 Application for Coventry Individual Health Insurance Underwritten by Coventry Health Care of Illinois, Inc. Primary Applicants Name Applicants Social Security NumberINSTRUCTIONS: Complete

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What is intentional misrepresentation may result?

Intentional misrepresentation may result in legal consequences such as fines or imprisonment.

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Anyone who has knowingly provided false information or withheld relevant details may be required to file intentional misrepresentation.

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The purpose of intentional misrepresentation may result is to ensure honesty and integrity in reporting important information.

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All relevant details and accurate information must be reported on intentional misrepresentation may result to avoid any legal consequences.

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