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Get Assignment Of Benefits Form Template

Please retain copies for your files as original receipts will not be returned. 1 Plan member information Plan no. Acct./Div. no. Certificate no. Plan sponsor Birthdate (dd/mmm/yyyy) Plan member name (first, middle initial, last) You can obtain your plan no., account/division no. and your certificate no. from your I.D. card. Plan member address (number, street and apt.) City or town Province Postal code Are these expenses eligible for coverage under any type of workers' compensation.

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