Document rBoe38xQBNmy2Jk9qMMewRjnr
FILE NAME Keene KNE DATE September 12 1968
DOC KNE007
DOCUMENT DESCRIPTION 1968 Sept 12 Insurance claim for Henry
Carroll
@ ronrtual life insurance eomapany
CLAIM FOR MONTHLY INCOME ACCIDENT AND SICKNESS BENEFITS
GROUP INSURANCE
Emploof y Emple oye
Le
oe pew
Henry Carrall
8146
8146 8146 Yer - Dowel
-
ett Dar
Pohry Numl
] V 11
& 14149
11
Yes
Month tay
Monthly umount Monthly Taesene
Fork Lift Dae Enpleyes was fos
pound
Operator
Se Thly
7
Thly
fscnms Dar 1266 Your 1266 HE HE resovered
9 1266 1266 of acre! bdity
Benefit for which
C) ane Mithly
Date
b^'neeh | Der , Yor Date work
Income inwered.9
Meow | Dey =, Tew
Ye
Waslayam curtidosta is form when this dimbility summeed !! No phones explain vader
Bammarn ......0.. 00. cece eer eec ne eser eens
con seennreneecsagens
Z
Was Empetres actively manged in work on 0 ful; time basis when this disability commmmend if Me piemas umpinan under St we seecese
8
tant teeneenee
g
bo shlity due to sicknom se injury arising out of any employment for wage w pondt If Ym pimas explain under Remertsacces cee ren sca sesssnces deesees we
.
To your dgs in Empleyes reviving or it he antitied to ressive besults from any other source becsum of this shomm If Yus piena arginin under Remarks
0:
Bamaste
i
.By
Dew
das. te" 11
rT
. tents DST Ya
(
M.
223
Strant
Brook Street
Tore
Bryn Mawr
heartdisesse
sun
Pz
Date first trusted for this aickoess oF
intury
Your 9-10-66 9-10-66 9-10-66
hana
DLY
If due to injury give date of accident
If due to injury where and how did secident conur?
Ou what dat ure you first unable to work becsum of this disability
On what date were you first abis to | rettu o wrornk
If total disability has not ended wha do you expitetocmatd
+
Ma
Gas
-
Your
.
Names of hospitals and dates of unfinement for this sickness or injury
The ddyy Marshal
the 15266 Pine
15266
DATE
Names and addresses of all physicians
confos r thiu s sil cknat m oe r ind jury
Chleb Chleb march 196
aT CaaS W Leame troms ey Wf tbs 200 aame low wr aay eat sour bemum of th Gina or Pied Wf aboeost
.
Ya Ne
1000 200 *
Forkmen's Composantion Social Encurity Retirement or Pennino Pisa
1000
Wel orf Wela farr e Fe ina Salary Contiusace Pina Any Individual Insurance Policy
HE
,yun wre receiving or intend to claim temalies from say of the shart - pineae furnish the Zowing Zowing partimala
moe
Name of sou
Amurant of
Amurant
pum wkly
able *?ae mitiv mitiv etc.
Name of couRPG
~
7S
rae
-
oe
a.
Fat yar tk:
la oe
.
. deo
a.
ae
.
Amount of
| Masenta -
_
{
How
PHU Phi
Lam ngo ngo