CLAIM FOR A DESIGNATED MEDICAL CONDITION Sample Clauses

CLAIM FOR A DESIGNATED MEDICAL CONDITION. Do you wish to make a claim for compensation for compensation for one or more Designated Medical Conditions, as defined in the Agreement and Exhibit A-2 thereto? If so, what are the Designated Medical Conditions for which you are making a claim? (Check all that apply.) Sclerosis/Scleroderma Systemic Lupus Erythematosus Atypical Neurological Disease Syndrome Mixed Connective Tissue Disease/Overlap Syndrome Polymyositis Dermatomyositis Primary Xxxxxxx’x Syndrome Atypical Connective Tissue Disease Atypical Rheumatic Syndrome Nonspecific Autoimmune Condition If you checked one of the Designated Medical Conditions above, please specify:
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Related to CLAIM FOR A DESIGNATED MEDICAL CONDITION

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