STATE OF MICHIGAN
LONG TERM DISABILITY CLAIM FORM. Is this a Workers’ Compensation Claim Yes No Send to: Citizens Management Inc. P.O. Box 740. Howell, Michigan 48844-0740. Phone: 800- 324-9901 Fax: 517- 540-3100. Email: SOMCLAIM@HANOVER.COM *CMI is the State’s Third Party Administrator (TPA) Please Notify and Send Your Human Resource Office a Copy ................
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