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Get Standard Insurance Company Medical History Statement Medical ... - Per Lacity

Tion Practices Notice(s) on page 3. A separate form must be submitted for each applicant (Employee/Member, Spouse and/or Child) when Evidence Of Insurability or Proof of Good Health is required to apply for coverage. Complete all items, date and sign in the space at the bottom of page 2. Keep a copy for your records, and send the original to Standard Insurance Company at the address given above. MEMBER/EMPLOYEE INFORMATION Name of Group Group Number Check who is Applying (One per form) Member.

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