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Get Afgidavit In Secure Life Form

IT YOUR CLAIM PLEASE PRINT 1. Complete Part A below as it applies to this claim. Date and sign for all claims. 2. Have your attending physician complete Part B. 3. When you and your attending physician have completed the form, in detail, attach the requested requirements and forward to us for review and processing to P.O. Box 4277, Houston, TX 77210-4277. PART A TO BE COMPLETED BY INSURED Please Note: Failure to complete this form IN FULL may delay the review of your claim. 1. Policyholder.

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