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Insurance Request

Required documentation for each applicant: -Photo identification for primary applicant -Projected total gross income (last 4 pay stubs or letter of verification) -Tax Return Forms for previous year (if filed) -Social Security Number for applicant and EACH household member -Email Address -Insurance card, cost and term date if ending (if currently insured)

Mailing Address (including City/State/Zip)
  • {name}
Permission: I wish to speak to someone to discuss insurance options and give permission for a representative of Southern Tier Health Care System to contact me.

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