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Reliance Standard Life Insurance Company will pursue any and all appropriate legal remedies arising from such fraudulent insurance acts. If left blank we will assume that 100 of premium is paid by employer and that employee was not taxed. EMPLOYER/ADMINISTRATOR SIGNATURE submits any information in conjunctions with a claim containing fraudulent false misleading incomplete or deceptive information commits a fraudulent insurance act which is a crime. PART C HEALTH CARE SERVICE PROVIDER...

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