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MMO/CLIC USE ONLY EFFECTIVE DATE: / / GROUP NUMBER: Health and Life Application/Change Form Ohio INSTRUCTIONS: All questions must be answered. Incomplete applications will be returned. Section I:

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Medical Mutual of Ohio is a health insurance company based in Ohio.

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Employers offering health insurance plans through Medical Mutual of Ohio are required to file.

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The purpose of Medical Mutual of Ohio is to provide health insurance coverage to individuals and employers in Ohio.

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Information such as employee demographic data, plan information, and enrollment details must be reported on Medical Mutual of Ohio forms.

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