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877) 404-6457 NOTE: All portions of this form package must be completed to avoid undue delay in processing claimant's request for benefits. APPLICATION FOR LTD BENEFITS Employee's Instructions A. Complete employee claim statement in full, and be sure to sign the Authorization. This will allow Dearborn National or its representative to secure additional information if necessary to make a decision on your claim. B. Give this form to the physician treating you. (If more than on.

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