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Get Manulife GL3586E 2003

IF DENTURE CROWN OR BRIDGE IS THIS INITIAL PLACEMENT GIVE DATE OF PRIOR PLACEMENT AND REASON FOR REPLACEMENT. PURPOSES Please complete both pages of this form. The Manufacturers Life Insurance Company Page 1 of 2 GL3607E 12/2003 I CERTIFY THAT THE INFORMATION IN THIS FORM IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND DOES NOT CONTAIN A CLAIM FOR ANY EXPENSES PREVIOUSLY PAID FOR BY ANY PLAN. I AUTHORIZE ANY PERSON OR ORGANIZATION WHO HAS IN.

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