| Document Date: 2014-10-10 19:24:55
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City Portland / / Company Standard Insurance Company / MIB Inc. / Medical Information Bureau Inc. / Immune Deficiency Syndrome / / Event Name Change / / Facility AIDS-Related Complex / University Employee Name Occupation Group Number / Medical Facility / / IndustryTerm insurance coverage / insurance / / MedicalCondition HIV infection / pneumonia / A. High blood pressure / F. Blindness / HIV / arteriosclerosis / nervous system disorder / G. An immune system disorder / D. Arthritis / C. Cancer / stroke / nephritis / diabetes / cardiovascular disease / sickness / persistent cough / persistent fatigue / injury / deafness / muscle disorder / epilepsy / depression / Injuries / Disorders / / MedicalTreatment surgery / / Organization Indiana University / Medical Information Bureau / / / Position plan administrator / authorized representative / upon request / physician / No No No Yes Yes No No Yes Yes No No Yes Yes Yes No No No Physician / / ProvinceOrState Oregon / / URL www.mib.com / /
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Reset Standard Insurance Company Medical History Statement Medical Underwriting, 900 SW Fifth Avenue Portland OR 97204