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Get UCSD DP 402 2009

Return to: Group Market Disability Claims Liberty Life Assurance Company of Boston P.O. Box 7209 London, KY 40742-7209 Phone No.: 1-800-838-4461 Fax No.: 1-877-664-7264 EMPLOYEE/CLAIMANT NAME: CLAIM NO.: S.S. NO.: PART A: TO BE COMPLETED BY EMPLOYEE EMPLOYER/SPONSOR: UCSD Campus - - DATE OF BIRTH: AUTHORIZATION TO OBTAIN INFORMATION I authorize any licensed physician, medical provider, hospital, medical facility, HMO, pharmacy, government agency, including the Social Security Adminis.

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