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Rson acting on his or her behalf (as deemed necessary) for the purpose of confirming eligibility and assessing and managing the claim. Date: Signature of Claimant: SEE REVERSE FOR MORE INFORMATION In order to obtain prompt payment of your claim, did you Provide a void cheque to receive claim payments via EFT (Electronic Funds Transfer)? Complete and sign your claim form? Include your correct current address and postal code? Include original receipts? Include a copy of the Exp.

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