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I understand that I may terminate this arrangement at any time by writing to the RSL address above. A statement of Reliance Standard Life Insurance Company s privacy policy is available at www. rsli. Insured s Signature Telephone Number P. O. Box 7749 AUTHORIZATION FOR USE IN OBTAINING INFORMATION NAME OF INSURED INSURED S DATE OF BIRTH POLICYHOLDER To all physicians and other health care professionals hospitals other health care institutions insurers medical hospital and prepaid health plans...
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