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Get Canada GSC Dental Accident Report Form 2021-2024

THE COMPLETION OF THIS REPORT. GREEN SHIELD NUMBER: NAME: ADDRESS: CITY/PROV/POSTAL CODE: PHONE NUMBER: ( ) DATE OF BIRTH: (YY/MM/DD) RELATIONSHIP TO PLAN MEMBER: MANDATORY DECLARATION Do you have any other group insurance coverage that may include these services as benefits? Yes No If yes, insurance company name: If other coverage is Green Shield Canada, indicate Green Shield Number: Is treatment required due to a motor vehicle accident? Yes No Is treatment required due to a work-rela.

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