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VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Information Insurance Primary Secondary Insurance CompanyInsurance Telephone 1Insurance Telephone 2Insurance ID #Group #Name of InsuredDate of Birth Insured EmployerWorker’s Comp Yes No Auto Accident Yes No Date Accident WCB/NF. Insurance CoAgentAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneClaim NumberCase/Policy #Assignment and release: I hereby authorize my insurance benefits to be paid directly to Shoshan Stockelberg. I will accept financial responsibility for non-covered services. In the event that my account is sent to a collection agency, I agree that I will be responsible for all collection costs. I also authorize Shoshana Stockelberg to release information services rendered by her to my insurance carrier and allow a photocopy of my signature to be used to file insurance claims. SignatureCAPTCHA