Page 1 of 5 Utah Small Employer Health Insurance Application July 2009 D. WAIVER OF COVERAGE Complete this section for yourself if waiving and/or any of your dependents for whom you are waiving coverage. UTAH SMALL EMPLOYER HEALTH INSURANCE APPLICATION OFFICE USE ONLY Policy / Group No. REASON FOR ENROLLMENT mark all that apply New Group Newborn Loss of Coverage Open Enrollment Marriage Court Order New Hire...
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