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Amoplans. com Email amomedical amoplans. com For AMO Plans Use Only Received Date Received By PERMANENT DATA AND 2017 AFFIDAVIT OF PENSIONER S MEDICAL BENEFITS EARNINGS LIMITATION AND COORDINATION OF BENEFITS To be completed by both the Pensioner and Dependent Spouse. In order for this form to be accepted you must answer every question. PENSIONER INFORMATION 1. Pensioner s Name SSN XXX-XX- Street Address DOB City Home Phone No. State Cell Phone No. Is this your mailing address Yes Zip Email...
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