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I understand that any false or fraudulent statement made herein may subject me to penalties as prescribed by law. Authorized EMPLOYER S Name Print Title - Employer s Phone ADDITIONAL SECTIONS ON THE BACK OF THIS FORM PART 3 ATTENDING PHYSICIAN S STATEMENT TO BE FILLED OUT BY PHYSICIAN ONLY In order to be paid for the first day of disability or to be paid beyond the first week of disability this section must be completed by your doctor. DRUG TRUST SICK LEAVE CLAIM FORM/DISABILITY EXTENSION APPLI ...

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