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Get NY G1205-TC 2012-2024

Ce Program (Program) of Name of Employer/Policyholder Insured’s Social Security No. / / Name of Insured Insured’s Address Group Policy No. Insured's Phone Number Group Certificate No. (if known) Has a Continued Protection (Waiver of Premium) claim been approved for the insured? “Certificate” Yes No Spouse Waiver for Assignment of Group Life Benefits (To Be Completed If Applicable) Please Read the Following Section Carefully: The spouse of the assignor should sign below IF the a.

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