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Get and Sign Instruction Sheet for Form Hc 5 Employee Notification to Employer 2015
Health care coverage
• You are changing your principal and/or secondary employer designation**
Do not use this form if either:
• You work for only 1 employer and that employer provides your health care coverage
• You work less than 20 hours per week for your employer
**The principal employer is the employer who pays you the most wages. Or if you work for 1 of your employers at least
35 hours a week but that employer does not pay you the most wages, you choose which employer is the...
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