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Get TN LB-0381 2012

THIS FORM COVERS: RFA # Temporary Disability Benefits 25% Penalty (For Late or Non-Payment of Benefits) Medical Benefits Discovery Issues Open Medical Coverage PLEASE NOTE: ALL FIELDS MARKED WITH AN ASTERISK *ARE MANDATORY Failure to complete the required information on this form shall result in the form being returned to the requesting party for completion. * Please give a brief explanation of disputed issues: A) *SOCIAL SECURITY NUMBER: *DATE of INJURY: * BIRTH: *EMPLOYEE’S NAME: .

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