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STATE OF ARIZONA ACTIVE 2010 SPECIAL ENROLLMENT FORM August 16 through September 15, 2010, DATE RECEIVED AGENCY EFFECTIVE DATE EMPLOYEE IDENTIFICATION LAST NAME, FIRST NAME, M.I. EMPLOYEE EIN or SSN
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What is special enrollment form?
Special enrollment form is a document that allows individuals to enroll in a health insurance plan outside of the standard enrollment period.
Who is required to file special enrollment form?
Individuals who experience a qualifying life event, such as getting married or losing their job-based health coverage, are required to file a special enrollment form.
How to fill out special enrollment form?
To fill out a special enrollment form, you need to provide personal information, details about the qualifying life event, and any supporting documentation required by the health insurance provider.
What is the purpose of special enrollment form?
The purpose of the special enrollment form is to give individuals the opportunity to obtain health insurance coverage when they experience significant life changes outside of the regular enrollment period.
What information must be reported on special enrollment form?
The special enrollment form typically requires information such as the individual's name, address, date of birth, contact details, qualifying life event details, and any relevant supporting documents.
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