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G claimant’s request for benefits. If you have any questions when completing this form, please call our: Toll Free Number - (800) 320-4445 1. Complete "Employee - Initial Disability Benefits Claim Form" in full. 2. Have treating physician complete the "Physician - Initial Disability Claim Form" and return to you. 3. Have Employer complete the "Employer - Initial Claim Form" and return to you. 4. Submit all completed forms to the address below or you may fax all completed forms to our: Toll F.

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