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Request For Continuation of Medical Coverage For Handicapped Child Note:Employee Instructions: Complete Sections 1 through 7 on this form. Ask your physician to complete the Handicapped Child Attending
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Complete sections 1 through include personal information such as name, address, and social security number.
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All employees are required to file complete sections 1 through of the form.
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Complete sections 1 through can be filled out by providing accurate and up-to-date information as requested.
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The purpose of complete sections 1 through is to verify the identity and eligibility to work of the employee.
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Information such as name, date of birth, address, and social security number must be reported on complete sections 1 through.
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