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Employer Information
* Required Fields

Complete 'Doing Business as' name if applicable.

* Employer Tax ID: 
* Legal Company Name: 
Doing Business As Name
(if applicable): 
NAICS Code: 
* Street Address: 
 
* City: 
* State: 
* ZIP Code: 
UHC Medical Customer Number: 
* # of Eligible Employees: 


     
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