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Get Canada Life 10231 CAN 2005-2024

occupation From (day, month, year) To (day, month, year) or ➧ at light or modified duties at any occupation? From (day, month, year) 11. Remarks – Please provide comments and further details which you feel would be helpful Name of attending physician (please print) Specialty Telephone no. (including area code) ( ) — Address (number, street, city, province, postal code) Signature of physician Date (day, month, year) Canadian Life and Health Insurance Association Inc. .

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