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If this statement changes in any way I agree to contact The Trust Fund office immediately. Participant s Signature Plan Member Month Day Year Any person making a willful misrepresentation in completing this form shall be liable to the Plan for any loss to the Plan resulting from such misrepresentation. Refer to the Summary Plan Description Section Coordination of Benefits with Other Plans for the specific Plan provision.. Trust Fund Office LABORERS HEALTH WELFARE TRUST FOR SOUTHERN CALIFORNIA...

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