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About the insured or any other information or records about the insured in its possession that is requested while administering this claim. I agree that a photocopy of this authorization shall be as valid as the original. Claimant Signature Date Rev.4.2017 Page 2 PARAMEDICAL/MEDICAL CLAIM FORM CHECKLIST Before you submit a completed claim form to Chubb Life Insurance, please review this checklist to avoid any delay in processing of your claim: Have you fully completed and signed the app.

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