Page 23 - Tritrax Benefit Guide Effective 9-1-2020
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Marketplace Coverage Options




                    New                                                                                  Form Approved
                                                                                                      OMB No.
                                  and Your


          PART B: Informa on About Health Coverage Offered by Your Employer
          This section contains information about any health coverage offered by your employer. If you decide to
          complete an application for coverage in the Marketplace, you will be asked to provide this information. This
          information is numbered to correspond to the Marketplace application.

























































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