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Get Sf 2823 Revised June 2021

Important: Read instructions on the Back of Part 2 before completing this form. A. Information About the Insured (not the Assignee, if there is one) (type or print) Name of Insured (Last, first, middle) Date of birth of Insured (mm/dd/yyyy) an employee The Insured is: Place an "X" in the appropriate box. Social Security Number of Insured If the Insured is retired or receiving Federal Employees' Compensation, give CSA, CSI, or OWCP claim number: a retiree a compensationer Department or.

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