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TO BE FULLY COMPLETED BY EMPLOYEE AND FILED WITHIN …

district council 37 health & security plan 55 water street, new york, ny 10041 this is a writable form short-term disability benefit claim hs:dis 013 phone: (212) 815-1 390 to be fully completed by employee and filed within 15 days from the day you become disabled

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  Disabled, Become, Become disabled

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