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IS PATIENT'S CONDITION RELATED TO:ColorclWhite Font.CharsetDEFAULT_CHARSET Font.ColorclBlack Font.Height Font.NameArial Font.Style ParentFont TransparentWordWrap FontSizeShape44_Injury_Illness1m1wwwѦ@T>ZTPF0 TQrdShapeShape44LeftTopWidthHeightHint Shape object Frame.ColorclBlack Frame.DrawTopFrame.DrawBottomFrame.DrawLeftFrame.DrawRight Size.ValuesXUUUUU@@ @TUUUUU @ Brush.StylebsClear Pen.ColorclSilverShape qrsHorLineText724_Injury_Illness1m1wwwѦ@T>ZTPF0 TQrdLabelText72LeftTopuWidthHeightHintStatic text field Frame.ColorclBlack Frame.DrawTopFrame.DrawBottomFrame.DrawLeftFrame.DrawRight Size.Values@@VUUUUU@@ Alignment taLeftJustify AlignToBandAutoSize AutoStretchCaption"c. EMPLOYER'S NAME OR SCHOOL NAMEColorclWhite Font.CharsetDEFAULT_CHARSET Font.ColorclBlack Font.Height Font.NameArial Font.Style ParentFont Transparent WordWrap FontSizeText734_Injury_Illness1m1wwwѦ@T>ZTPF0 TQrdLabelText73LeftTopWidthHeightHintStatic text field Frame.ColorclBlack Frame.DrawTopFrame.DrawBottomFrame.DrawLeftFrame.DrawRight Size.Values@@ @b@ Alignment taLeftJustify AlignToBandAutoSize AutoStretchCaption'd. 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EMPLOYMENT? (CURRENT OR PREVIOUS)ColorclWhite Font.CharsetDEFAULT_CHARSET Font.ColorclBlack Font.Height Font.NameArial Font.Style ParentFont Transparent WordWrap FontSizeText874_Injury_Illness1m1wwwѦ@T>ZTPF0 TQrdLabelText87LeftTopTWidthNHeightHintStatic text field Frame.ColorclBlack Frame.DrawTopFrame.DrawBottomFrame.DrawLeftFrame.DrawRight Size.Values@@UUUUUU@`@ Alignment taLeftJustify AlignToBandAutoSize AutoStretchCaptionb. AUTO ACCIDENT?ColorclWhite Font.CharsetDEFAULT_CHARSET Font.ColorclBlack Font.Height Font.NameArial Font.Style ParentFont Transparent WordWrap FontSizeText884_Injury_Illness1m1wwwѦ@T>ZTPF0 TQrdLabelText88LeftTopuWidthTHeightHintStatic text field Frame.ColorclBlack Frame.DrawTopFrame.DrawBottomFrame.DrawLeftFrame.DrawRight Size.Values@@VUUUUU@@@ Alignment taLeftJustify AlignToBandAutoSize AutoStretchCaptionc. 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PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE. I authorize the release of any medical or other information necessaryColorclWhite Font.CharsetDEFAULT_CHARSET Font.ColorclBlack Font.Height Font.NameArial Font.Style ParentFont TransparentWordWrap FontSizeText984_Injury_Illness1m1wwwѦ@T>ZTPF0 TQrdLabelText98LeftTopWidthHeightHintStatic text field Frame.ColorclBlack Frame.DrawTopFrame.DrawBottomFrame.DrawLeftFrame.DrawRight Size.Values@ @ҕ @ @ Alignment taLeftJustify AlignToBandAutoSize AutoStretchCaption}to process this claim. 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