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Get Solicitud Por Incapacidad A Corto Plazo

4. Direcci n residencial M F 5. Direcci n postal (Incluya zip code) 6. Fecha de nacimiento (mes-d a-a o) 7. Ocupaci n 8. Antes de incapacitarme, trabaj hasta (fecha) 9. Me incapacit por (Explique c mo, cu ndo, d nde y en que fecha ocurri su incapacidad) 10. Mi patrono a la fecha de incapacidad es (era): 11. Mi incapacidad est relacionada con: (En caso afirmativo, incluya copia de la determinaci n o de los documentos) Fecha exacta de su incapacidad: SI NO Mi trabajo.

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