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NY SBG 180 East Main Street, Suite 205, Pathogen, NY 11772 1-800-456-9724 Fax (631) 654-0840 2012-2013 Association Plans for groups of 1 Effective 4/1/12-3/31/13 Below is your Request for Plan Change
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How to fill out plan selection form 2012-13qxp:
01
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02
Gather all the necessary documents and information you will need to complete the form. This may include personal identification, financial information, and any relevant supporting documents.
03
Begin filling out the personal details section of the form. This typically includes your full name, address, contact information, and any other requested personal details.
04
Move on to the section that pertains to your specific plan selection. This could involve choosing between different options, indicating your preferences, or providing additional information related to your desired plan.
05
If required, fill out any sections related to dependents or family members who will be covered under the selected plan. Provide their names, ages, and any other requested information.
06
Review the completed form for accuracy and make any necessary corrections. Double-check that all required fields have been filled out and that the information provided is correct and up-to-date.
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Sign and date the form as required. Some forms may require additional signatures from a supervisor, healthcare provider, or other relevant parties.
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Who needs plan selection form 2012-13qxp:
01
Individuals or employees who are part of a healthcare or insurance plan that requires them to make plan selections.
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Those who are renewing their current plan or exploring different options within the available plans.
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Individuals who need to provide information about their dependent(s) or family members who will be covered under the selected plan.
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