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E MP LOYE R VE R IF IC AT ION OF HE ALT H INS UR ANC E INS T R UC T IONS T his form will be s canne d, ple as e write cle arly. Us e blue or black ink. Write all date s in the mm/dd/yy format. F or e xample , [removed].
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Document Date: 2005-06-21 10:08:36
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E MP LOYE R VE R IF IC AT ION OF HE ALT H INS UR ANC E INS T R UC T IONS T his form will be s canne d, ple as e write cle arly. Us e blue or black ink. Write all date s in the mm/dd/yy format. F or e xample , [removed].