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Get Coughlin Medical Expense Claim Form

MEDICAL EXPENSE CLAIM FORM Send all claims and inquiries to Print Form Plan Member - insured Group or employer Personal Identification No. Full Name Date of Birth Address Language Preference City Province Postal Code y m d English French Tel. local - 204 942-4438 toll free - 1-888-204-1234 Work Telephone No. Residence Telephone No. ext. Are any health benefits or services provided under any other group insurance or health plan workers compensatio.

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