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Get UCSD DP 402 2013-2024

Completed without expense to Lincoln Financial and returned along with your original claim for benefi ts or by the date requested by the Lincoln Financial Claims Dept. Return to: EMPLOYEE/CLAIMANT NAME: CLAIM NO.: EMPLOYER/SPONSOR: UCSD Campus S.S. NO.: - - DATE OF BIRTH: PART A: TO BE COMPLETED BY EMPLOYEE Authorization to Obtain and Release Information I authorize any licensed physician, medical provider, hospital, medical facility, pharmacy, government agency, including the Social Secu.

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