HomeMy WebLinkAboutGuardian 6.27-7.10 Landon.PDFCUA IAN'
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The Guardian Life Insurance
Company of America
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PO BOX 14332
LEXINGTON KY 40512-(800) 268-2s25
OR WWW. GUARDIANANYTXME . COM
62020552807
JAMES S LANDON
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VILLAGE OF CAYUGA HEXGHTS
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VILLAGE OF CAYUGA HEIGHTS
CORRESPONDENT
836 rnHsHAw RoAD
I THACA NY r4850-1548
IF YOU HAVE
ANY QUESTIONS
CONTACT:
CLAIM NO.:
EMPLOYEE NAME:
EMPLOYEE ID:
PLAN NO.;
PLANHOLDER:
DATE:
THE FOLLOWING IS AN EXPLANATION OF YOUR SHORT - TERM DISABILITY BENEFITS
DATES OF DISABILITY NO. OF WEEKS/DAYS GROSS BENEFIT
DEDUCTIONS NET
AMOUNT
PAID
FICA: SOCIAL
SECURITY
FICA:
MEDICARE FIT OTHER
06127 - 07 l10l16 ozlsa U'}U. UU O+U, UU
IVAXIMUIV WEEKLYALLOWABLE BENEFIT HAS BEEN GIVEN,
YOUR PHYSICIAN HAS PROVIDED AN UPDATED RETURN TO WORK OF 7111116
THIS CHECK REPRESENTS SALARY CONTINUANCE PAID TO YOUR EI\,{PLOYER
IMPORTANT! SAVE THIS STATEMENT FOR TAX PURPOSES, SEE REVER$E SIDE FOR IMPORTANT NOTICES.
CHECK NO., AMOUNT
AND PAYEE:
oo15750514 $340. OO VILLAGE OF CAYUGA HEIGHTS
EOB-STD1-0s
PLANH@LDER G@PY