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PO Box 3507 Missoula, MT 598063507 18007373137 or (406) 5233122Date: Claim #: ___ Name of Treating Physician: ___ Date of Service: ___ Injured Person: ___ Name of Employer/Plan Sponsor: ___ Policyholder:

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What is contact us - allegiance?

Contact us - allegiance is a form or declaration that individuals or organizations are required to file with a specific authority to show their loyalty or support.

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Individuals or organizations who are obligated by law or regulations to demonstrate their allegiance or support.

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The purpose of contact us - allegiance is to ensure that individuals or organizations are adhering to the required loyalty or support to a specific authority or entity.

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The information required on contact us - allegiance forms may vary but often include personal or organizational details, declaration of loyalty or support, and signature.

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