Get Allianz Physician Statement Form
___________________ ________________________________________________ ________________________________________________ ________________________________________________ If the patient is the insured, on what date did he/she become medically unable to travel? ___ / ___ / ________ By my signature and stamp below, I hereby certify that the above is true and correct Physician Signature: _________________________________________________ Date ____/____/______ Physician Stamp: E-mail to: claimsi.
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