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Click ‘Get Form’ to open it in the editor.
Begin with the Employee’s Statement. Fill in your full name, Social Security number, address, and contact information. Ensure all fields are completed; if a question does not apply, write 'NA'.
Proceed to the Employment section. Provide details about your employer, job title, and describe your duties. Indicate the last day you worked and the cause of your disability.
In the Sickness/Injury section, describe your condition thoroughly. Include dates and any previous related illnesses.
Complete the Attending Physician’s Statement by having your physician fill out Part B. Ensure they provide necessary medical details.
Finally, review all sections for completeness before signing and dating your statement to avoid delays in processing.
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