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Formulario de declaración de accidente/enfermedad inesperada

[/vc_column_text][vc_empty_space height=”20px”][vc_column_text]Asegúrese de completar este formulario con precisión para recibir un servicio rápido y eficaz.[/vc_column_text][vc_empty_space height=”20px”][vc_column_text]Junto con el formulario, adjunte también:

  • Una copia de un informe médico que detalla el diagnóstico médico
  • copias de recibos pagados

Si no tiene estos documentos ahora, puede enviarlos en una etapa posterior.[/vc_column_text][vc_empty_space height=”40px”]

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    Accident/unexpected Illness declaration form

    Please make sure to complete this form accurately to receive an effective and fast service.

    Along with the form, please also attach:

    • a copy of a medical report that details the medical diagnosis

    • copies of paid receipts

    If you do not have these documents now, you can send them at a later stage.

    Insured Member Details

    Place and time of the accident/unexpected illness

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    Type of accident/unexpected illness

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