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Formulaire de déclaration d’accident ou de maladie inattendue

[/vc_column_text][vc_empty_space height=”20px”][vc_column_text]Veuillez remplir ce formulaire avec précision pour pouvoir bénéficier d’une prise en charge efficace et rapide.
[/vc_column_text][vc_empty_space height=”20px”][vc_column_text]En complément du formulaire, merci de joindre :

  • une copie du rapport médical détaillant le diagnostic médical
  • les copies des factures réglées

Si vous n’avez pas encore ces documents, vous pourrez les envoyer ultérieurement.[/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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