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Fit to work for specified From : D D / M M / Y Y Y Y number of days. To : D D / M M / Y Y Y Y D D / M M / Y Y Y Y Fitness Date to join Duties 5. (i) Has the accident resulted into loss of hand/s or foot/feet or eye/s or permanent disability of any other type which may prevent the insured from engaging in or being occupied with or giving attention to any employment or occupation whatsoever? Yes No (ii) If yes, please give details : Signature of the competent Authority of.
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