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Get NY LS 425 2013-2022

- surgical Bonus Expenses Other (specify) 35. Total amount claimed $ 36. Did this employer previously pay this type of benefit to you? A. For what period? ______________________________ B. Who paid the benefits? Employer Union Yes No Amount $ _________________________________ Other (explain; e.g., Blue Cross, HIP) 37. What kind of agreement covers this benefit? If based upon a written document, attach a copy. Company policy Oral Union contract Other (explain) Written (specify, e.g., .

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