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Waiver Form to Decline Health Care Coverage (00076189-3)

Return the form to the Benefits Office: fax 919-962-6010 or CB 1045 {00076189.DOCX 3} Section 2 – To be completed by employee at time of hire or time of measurement if employee is determined to be eligible for health coverage. I currently work for another unit of UNC-CH and/or another constituent institution of The University of North Carolina (for a

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