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Fillable CONTINUING DISABILITY CLAIM FORM

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CONTINUING DISABILITY CLAIM FORM Failure to complete this form in its entirety may result in a delay in processing this claim. FILING CLAIM FOR (check all that apply): Disability due to an Accident Disability due to a Sickness Disability due to Pregnancy / Complications Short-Term Disability Policy Number Disability due to Cancer Accident Policy Number � � � INSTRUCTIONS: Complete Section A: Policyholder/Patient Information. Your doctor should complete and sign Section B: Physician's Disability Statement More

Name	continued disability claim

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