Coalition for Healthcare

Enrollment Form

Hospital Indemnity

(When submitting address please include zip code)
Immigration Status*
Name, Date of Birth and SSN for Spouse and Children
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NOTE:

1. If submitting Permanent Green Card or Work Authorization attach a copy of front and back of card.

2. If submitting Foreign Passport please attach copy of Passport.

PLEASE NOTE THAT ANY ATTACHMENT SHOULD BE SENT TO [email protected]


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