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Get Virginia Retirement System Accidental Dismemberment ... - LifeBenefits

Ormation Call: Toll Free 1-800-441-2258 CLAIMANT S STATEMENT To present your claim for benefits, complete this Claimant s Statement. All questions must be fully completed. Have your physician complete the Attending Physician s Statement and attach copies of your medical records. Please be sure to sign and date the authorization. 1. NAME OF EMPLOYEE (Last First Middle Initial) 4. ADDRESS 2. SOCIAL SECURITY NUMBER CITY CLAIMANT S LEGAL NAME (Last, First, Middle Initial) 3. DATE OF BI.

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