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City of San Diego Risk Management

LTD@sandiego.gov

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03/14/2026Click to Sign
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Marital Status
Dependent Children
Same illness before?
Accident a.m. or p.m.
Accident caused by another party?
Police Report?
Pregnancy foreseeable complications?
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Wage - City of SD
Wage - other
Wages - Self
Retirement - City of SD
Retirement - Other
Disability Benefits - Group Life Ins
Disability - Group Plan
Insurance - Retirement Plan
Govt. Source - SS
Govt. Sources - Industrial Leave
Govt. Services - Workers' Comp
Govt. Services - Unemployment
Govt. Sources - State Disability Ins.
Govt. Sources - Welfare
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Income other
Income Other (expect)
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