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Get Lincoln GLC-01544 2011-2024

Om (Check applicable box) h Occupational illness/injury h Auto accident h Other accident 47. Auto Accident State 46. Date of Accident (MM/DD/CCYY) TREATING DENTIST AND TREATMENT LOCATION Subscriber Signature Date 53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) or have been completed and that the fees submitted are the actual BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity fees I have charged.

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