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 Here is an example of a filled out form with instructions for filling in the boxes. 

Note: if you pre-fill a field  field like country with "United States" Docusign will do some weird stuff and fill that in other boxes with that same info, if this happens you may just  have to delete those auto-filled fields and type in the correct info(issue we're working on)

Section C:

Box 1. Employee SSN

Box 2a. Three boxes: (Legal name)

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• Email address:
• Telephone Number (box to the right of email):
• Work telephone (box below email):
• Fax Number - put "NA"

Section D: Individuals Covered

• First Box: leave as "A" Add
• Relation Code: Use drop down to select from the following:
  • EE - Employee (re-type the employee's info on this row to cover them self on this policy)
  • W = Wife
  • H = Husband
  • D = Daughter
  • S = Son
• Name - Last, First, Middle Initial 
• US Social Security Number XXX-XX-XXXX
• Birth date MM/DD/YYYY
• Skip 5 check boxes - not required
• Primary Country of Citizenship - USA 
• Residence (Indicate if same or Different than the employee (ex. children covered under plan but living in different country for school etc.. ) 
  • If different we may ask for the mailing address separately 

Section E: Acknowledgements - Signatures Required

• E-sign the employees name, date

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