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Get Public Safety Officer Authorization For Insurance Premium Deduction - In

Sed without this information. Public Safety Officer Authorization for Insurance Premium Deduction Reset Instructions Use this form to elect to have your insurance premiums paid directly to your insurance provider and the cost deducted from your monthly benefit. STEP 1: Member Information (Please Print) Social Security Number Date (MM/DD/YYYY) First Name Last Name MI Address City State Daytime Phone Evening Phone Zip Code Email Address Employer at time of Retirement Job or Positi.

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