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Medical records must be submitted for further benefit consideration. No Yes For dates: Likewise Assurance Company P.O. Box 2272 Seattle, WA 98111-2272 Telephone: (425) 918-4575 Toll-Free (800) 258-0394

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How to Fill Out This Form Must Be:

1. Start by carefully reading the instructions provided on the form. Make sure you understand the purpose of the form and the information that needs to be filled out.
2. Begin by providing your personal information, such as your name, address, contact details, and any other required identification information.
3. Follow the indicated format for filling out dates, such as using the day-month-year format (dd-mm-yyyy) or the month-day-year format (mm-dd-yyyy), depending on the requirement.
4. Provide accurate and up-to-date information in the relevant sections. If any section does not apply to you, leave it blank or write N/A (not applicable).
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8. Sign and date the form where required, following the specified format.
9. Submit the filled-out form through the designated method, such as mailing it, submitting it online, or hand-delivering it to the appropriate person or office.

Who Needs This Form Must Be:

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What is this form must be?

This form is a tax form.

Who is required to file this form must be?

Individuals and businesses with taxable income.

How to fill out this form must be?

The form must be filled out with accurate and complete information.

What is the purpose of this form must be?

The purpose of this form is to report taxable income.

What information must be reported on this form must be?

Information such as income, deductions, and credits must be reported on this form.