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Get USAble Life CL-WELLNESS 2013-2024

Information List your personal information. Thank you for selecting coverage from USAble Life. Complete this form to request your calendar year Wellness Benefit (if applicable to your policy). ● For clarity, the Insured is referred to as “you”, “your” and “patient” on this form. ● You may reach us with any questions at 800-370-5856, Monday-Friday, 8:00 a.m. to 5:00 p.m. CT. Insured’s name Social Security Number Birth date .

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