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1. CONTRACT ID CODEPENDENT OF SOLICITATION/MODIFICATION OF CONTRACT 2. AMENDMENT/MODIFICATION NO.3. EFFECTIVE DATE0001 6. ISSUED PAGE OF PAGESJ145. PROJECT NO.(If applicable)4. REQUISITION/PURCHASE

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Form insurance information provided is a document used to report details about insurance coverage provided by an employer to employees.

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Employers who provide insurance coverage to their employees are required to file form insurance information provided.

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