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Customer Name 
Effective Date
Zip Code
 Include Orthodontia?   No:   Yes:
 $1,500 Annual Maximum     
 Dental Benefit Option? No:   Yes:
 Waive Waiting Period?   No:   Yes:
 (Not available with Basic or Voluntary Plan)
 E + Spouse  
 E + Child(ren)  
 E + Family  
Total Employees   
Optional Term Life Product?  No:   Yes:
(Not available with Voluntary Plan)
Life Benefit:
Find SIC Code :  
< 3535-4950-6465+

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