(c) As part of any claim submitted and filed with the benefit provider, fire districts, departments and companies shall provide a certification of eligibility for enhanced cancer disability benefits using a form prescribed by the Office of Fire Prevention and Control. This form must be signed by the head of the department or company, sworn to under penalty of perjury as true, correct and complete, notarized and contain, at a minimum, the following information:

1. (1) the full legal name of the eligible volunteer firefighter;
2. (2) the full legal name of the fire district, department or company;
3. (3) the dates the eligible volunteer firefighter was an active volunteer firefighter of the fire district, department or company;
4. (4) the number of years of firefighting service as an interior firefighter;
5. (5) a statement that the eligible volunteer firefighter performed interior structural firefighting duties inside a building; and
6. (6) a statement that the eligible volunteer firefighter successfully completed a physical examination, prior to the commencement of duties as an interior firefighter, which failed to reveal any evidence of cancer.