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Get Disability Maternity Claim Form - Olde Fayetteville Insurance ...

T to the address or fax to the number below. Page Two Disability Claim Form - Employee s Statement Complete all questions in all sections of the Employee Statement Review the deduction of premium information. Page Three Authorization to Release Information The Authorization to allow physicians to release medical records to Kanawha Insurance Company, a Humana Company. Please make certain the Claimant or Authorized representative sign and date the form. Page Four Physician s Sta.

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