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Get UFCW & Employers Trust Sick Leave Claim Form/Disability Extension Application 2017-2024

UT BY EMPLOYEE ONLY) PART1 These sections must be completed by the Employee. Part 1-A and 1-B must be completed prior to the Employer completing their section. 1-A Home Phone# Last Name First Name Initial Date of Birth: Social Security# Mailing Address City State Zip Code Check if this address is an address change: D Date of Address Change: 1-B 1st Date Absent Due to Disability: Return-to-Work Date: (MM/DD/YYYY) (MM/DD/YYYY) Were you injured on the job? NOD YESD 1-C Injury.

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