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O. Box 7211 London KY 40742-7211 Phone No. 888-440-6118 Fax No. 603-422-0117 STD BENEFITS APPLIED FOR LTD Assurance Company of Boston TO BE COMPLETED BY EMPLOYEE PLEASE COMPLETE ALL APPLICABLE SPACES Employee s Name Employee s Social Security No. Street Address City Home Telephone No. Work Telephone No. State Sex Marital Status Zip Code Date of Birth M F Spouse s Name Single Widowed Spouse s Date of Birth Married Divorced List Names and Dates of Birth of Unmarried Children Who Have Not...
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