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1 To be completed by the Claimant: Part one through seven including the Authorization for Medical Records. Name of of Part One Instructions: Please indicate by checking the box next to each item if you now have, or have ever had any of the following conditions: Broken Bones – any part of the body Hemophilia Diabetes Rheumatic fever Torn Muscles, ligaments, cartilage Epilepsy Heart Disease/Heart attack Serious facial disfigurement Cancer of any kind Vision – Including color blindness Congenital defects/deformities Mental Illnesses Kidney disease Back problems Lung disease/Breathing problems Knee problems Diseases of other organs Chemical sensitivity Substance abuse Heart murmur Ear problems High blood pressure Speech problems Low blood pressure Arthritis Anemia Amputation Thyroid disease Polio Hepatitis Muscular Fainting or dizziness Tuberculosis Sports related injuries Dermatitis/other skin disease Other Asthma Part Two Instructions: Please indicate in the area below whether you have had prior disability, compensation or other insurance claim. Type of Claim / Insurance Company Type of Injury / Disease ---PAGE BREAK--- 2 Part Three Instructions: Please list any sports activities, hobbies or other activities you participate in on a regular or seasonal basis. Part Four Instructions: For each box that checked in Part One, please list the physician(s) you treated with, what for, where and when. Physician Disease / Injury Date / Location Part Five Instructions: Please provide the name, address and phone number for the physician you are currently treating with and for your family physician. Treating Physician: Address: Phone: Family Physician: Address: Phone: ---PAGE BREAK--- 3 Part Six Instructions: Please provide the following information: Phone Date of Social Security Street Address (if different from the Mailing Address): Claimant Claimant Today’s Part Seven Instructions: Please provide the name(s); address(es); phone number(s) and job description(s) regarding any other employment (full time, part-time, seasonal, etc.):