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Get and Sign Guardian Dependent Eligibility Certification Form 2004
Nature of disability (Please provide as much detail as possible):
Yes
No
4. Prognosis (estimate months or years):
5. Name and address of Primary Care Physician:
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST
OF MY KNOWLEDGE AND AUTHORIZE RELEASE OF ANY INFORMATION REQUEST
IN REGARD TO THE CERTIFICATION.
Member Signature
Date Signed
Any person who includes any false or misleading information on an application for insurance commits a fraudulent insurance act and is...
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