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Get Allstate Abj10368 2015-2025

It? _ a.m. p.m. Tell us exactly how your accident/injury happened: Yes No On the job Off the job Have you ever had a similar injury? If so, please tell us when: / / If you are claiming disability due to your accident, please have your physician complete the ATTENDING PHYSICIAN STATEMENT and your employer complete the EMPLOYER’S STATEMENT. ABJ10368-4 Page 1 of 6 (5/15) ASSIGNMENT OF BENEFITS FOR ACCIDENT COVERAGE (n/a in New Hampshire) I request that American Heritage Life Insurance .

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