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Get Canada AB-4 - Alberta 2006

N or after October 1, 2004 To be completed by Claimant / Representative or a Primary Health Care Practitioner Send this form to the appropriate insurer: Insurance Company Policy Number Fax # (____)______-_________ Date of Accident: (DD-MM-YYYY) Part 1 – Claimant Information Last Name First Name Date of Birth (DD/MM/YYYY) Date of Initial Assessment (DD/MM/YYYY) Part 2 – Information of Primary Health Care Practitioner Name of Professional Profession Address City, Town or County Pr.

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