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Additional information may be required. Please submit a copy of your payment statement with this form. Please have your treating physician complete the ATTENDING PHYSICIAN STATEMENT and your employer complete the EMPLOYER S STATEMENT. ABJ10368G-3 1 of 6 1/13 DISABILITY AND WAIVER OF PREMIUM CLAIMS CERTIFICATEHOLDER INJURY OR ILLNESS YOU ARE CLAIMING Date you were first treated for your illness or injury Date you were last treated for your illness or injury Date of your accident or the date...
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