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Get Formulir Klaim Axa Mandiri

At proses klaim harap semua peranyaan di bawah ini dijawab dengan benar, lengkap dan jelas. Yang bertandatangan di bawah ini A Data Pemegang Polis & tertanggung 1. Nama Pemegang Polis 2. Nama Tertanggung 3. No. Polis 4. Nomor Telepon / HP 5. Nomor KTP/Identitas lain Menerangkan bahwa : B Data Pasien 1. Nama Pasien 2. Nama panggilan / Nama lain / alias Jenis Kelamin - & 3. Tempat & Tanggal lahir tgl bln Pria Wanita / thn Tahun Usia 4. Nomor KTP/ Identitas lain C Telah dirawat inap.

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