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Administration Employer s Name and Address: Date: Employee s Name: Employee s Social Security Number: Claimant s Name: Claim Number: Dear Sir/Madam: We need the following information regarding the above claimant. Please answer the questions below, sign and date this letter and return it in the enclosed envelope. You may call at the above telephone number if you have any questions. Sincerely, Office Manager 1. Is (or was) the cl.

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