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AffordableONE
Phone Number
407-965-4166
Open Hours
8:30am - 5pm / Mon - Fri
Email Us
theywork4me@affordableone.com
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Group Health Employee
Group Health Employee Request
Employee Data
Company Name:
*
Zip Code
*
Employee Full Name
*
Birth Date
*
Gender
*
Male
Female
Smoker
*
Yes
No
Spouse
Spouse Full Name
Birth Date
Gender
Male
Female
Smoker
Yes
No
Child(ren)
Child 1
Child Full Name
Birth Date
Gender
Male
Female
Smoker
Yes
No
Child 2
Child Full Name
Birth Date
Gender
Male
Female
Smoker
Yes
No
Child 3
Child Full Name
Birth Date
Gender
Male
Female
Smoker
Yes
No
Child 4
Child Full Name
Birth Date
Gender
Male
Female
Smoker
Yes
No
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