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Get the free Claim for Disability Benefits - Alberta Finance and Enterprise - finance alberta

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You will need Acrobat Reader 6.0 or higher in order to complete this form online. Important Notice About Your Personal Information Claim for Disability Benefits Form AB-1A Print For accidents that
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County State Zip Phone (Optional) Signature (Optional) Claimant's Last Name First Name Middle Name Last Name : Email (Optional) Claimant's Address of residence City County State Zip (Optional) Birth Date: (DD-MM-YYYY) Month Year Date of birth: (MM-DD-YYYY) Month : Day of Birth: (MM-DD-YYYY) Year : Place of Birth: (MM-DD-YYYY) Zip Code: (Optional) Fax Number: (Optional) Claimant's Statement of Indicate how you want information entered in, including the following: (1) Claimant's name, date of birth, gender, citizenship, marital status (if applicable), occupation, marital status, and Social Security Number (if applicable); (2) If this statement contains personal information, the claimant must fill out all fields including gender, birthdate, and sex information, but they may exclude social security number; (3) If this statement includes social security number, the claimant must complete the last letter (s) of the Social Security Number field; (4) Indicate whether you want the information entered as a claim or a claim number instead of individual number, date of birth, or gender; (5) Indicate if you believe the accident caused physical or mental injury (or death); (6) If the statement contains a claim number, the claim number alone must be in the lower part of the form; and (7) Indicate if you want the claim number to appear as the only claim information type. Personal Injury Medical Benefits Claim Form AB-1AA Print For injury that occurs after October 1, 2004.

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