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Fax (402) 997-1865 Part I Employee Statement (ALL QUESTIONS MUST BE ANSWERED TO AVOID DELAY) Employer Name Policy Number Job Title Name Address City Hours Worked per Week State ZIP Social Security Number (Area Code) Phone Number Date of Birth Height Weight Date of Disability (1st Day Absent) (Mo.)/(Day)/(Year) Dominant Hand: Right Left Male Female Date First Treated (Mo.)/(Day)/(Year) Single Married Widowed Divorced Ph.

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