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NATIONAL ELEVATOR INDUSTRY SEND TO HEALTH BENEFIT PLAN PO Box 476 NEWTOWN SQUARE PA 19073-0476 PHONE 1-800-252-4611 FAX 610 557-4556 WEEKLY INCOME CLAIM FORM Instructions BOTH SIDES of this form must be completed. This form is not to be used for Members working in NY NJ HI TO BE COMPLETED BY PLAN MEMBER Name Social Security No. Street Birth Date Local Union No. City State Zip Code Phone Describe illness or injury Last day worked Was illness or i...
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