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Member Date Signed Name and Surname of the Principal Insured Member Broker Details Broker Name & Contact details BEFORE ANY CLAIM CAN BE SETTLED, COPIES OF THE FOLLOWING DOCUMENTATION RELATING TO THIS PARTICULAR CLAIM/S ARE REQUIRED: 1. Hospital Accounts 2. Doctors Accounts 3. Medical Aid Statement (Failure to provide all applicable documentation to this claim form will cause undue delay in the processing thereof.)DECLARATION Page 2 of 2.

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