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Waiver Premium Form
The form, including the instruction sheet, to your employee. Ask him/her to complete
the Employee Sections and return the claim form to The Hartford. (Your employee should detach the Attending
Physician's Statement Initial Report [Attending Physician Statement], pages 1 and 2, and forward to his/her
physician for completion).
5. SUBMIT THE EMPLOYER'S STATEMENT AND ATTACHMENTS DIRECTLY TO THE HARTFORD BEFORE THE
CLAIM SUBMISSION PERIOD* SPECIFIED UNDER THE POLICY.
** Please verify if the...
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