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LOCAL GOVERNMENT HEALTH INSURANCE PROGRAM 2012 DECLINATION OF COVERAGE FORM Form LG04 Revised 10/11 SUBSCRIBER INFORMATION Name First Middle Initial Last Social Security Number Sex Contract Number Date of Birth Work Telephone Number City Mailing Address Home Telephone Number State Zip Code I wish to decline coverage in the Local Government Health name of local government employee Insurance Program. I affirm that I currently have other group healt...
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