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OWA Medical Plan Monthly Rates - EFFECTIVE 12/01/17-11/30/18
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EMPLOYEE ENROLLMENT WORKSHEET FOR:
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Name: Effective:
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Subscriber's DOB:07/21/1983
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Dependent ENROLLMENT WORKSHEET FOR:
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Spouse
Spouse DOB:
0Age as of 4/1/2020N/a
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Dependent 1 Dep DOB0Age as of 8/20/2019N/a
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Dependent 2 Dep DOBAge as of 12/1/2017N/a
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Dependent 3 Dep DOBAge as of 12/1/2017N/a
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Dependent 4 Dep DOB0Age as of 12/1/2017N/a
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