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Tha sue ofthis Farm is alte be akon as 2 asin ot aby (Tabet ndacletes) DETALS OF RMA SURED: sews QOOODOOOOOOOOOOOOOOOO ses QOOOOO0000 aamreve QOOOOOOOOO0000000 OQOODSSOHE000000 000000000 000E0080000800000 ewes: OO OODODOOOOD0DO 00000 000000000 000000000000000 z OODOUOOOO0OU DOOO0000000000000000000000000 2 @ OOOOO00000000000000 oo0000000000000000u0 5 | eee 00000 ~ OOOOO0000d se acowtyoeubyersmeiinttaih hace To [te SOmctoremenmcttstherme wate JE] LE LL nearer a arson OOOOOOO000000 » OOO00O00R0000000000o sunset CICIDIDIID cieeybseresptaccincmwstyeastC] vs Ove ome] EID) owed srewiomymacicamionmee: Cs Oe — inmcmnne IODOOOOOCOOOCOUCoooo eee QODOSS0SS0000 000000 000000000u02b22E0e000080000 2) owe we Ore cel] om OE omen OE ON OO afatcraperimayesiee Sat E] SeaeC] OME) raw] semw C] ote [] penesqey) [> 4) owaipton —Sevce C]SaEreoed C] omens] stent] ated CE] ober C) ireesesveaty [SSCS—~*™ AMwutewetotes OOOOIIUOIOOUODOUOOOOOOOSSSSGS0000000 s DOOOOCS00000000000000000000000000000008000 s QODOOOCO00000000000 OO00000000800800005 reese 00000 - OOOOOS00000 se — 1S 2 NOLS TY otmnctiomieeemiet COO OODOO GOO COO COOoooooooooooooooooG fem cage eee Doe C] Siew heats Seamer i Momptazsten unis: Iny C)trese CJ atrnty C] ADechu/IthOinimcOoy OL OO OO somdsimn EIS) 60 GE aD ao (tmuyemens Steed C] St nC] utente he irpeweopte Cie Ce jpn! ae DETALSOF CLAM: ‘Ona teeter chit Propataten psaes &OOOOOOO ‘tice: 8. QOOO0OO _ cottincome: OOOO «twmomcwrce — SOOO OOD | 6 cvsrecsmanin Arann ee ®OO00000 «sees OOO = OO00000 | = “eee Tota ® DOOOOOO | 9 si. 1, Pretapalen pret eQ00 wroteon: os OOO “eral BIPavns Faso ‘orp Sunray 2) chimtrDometnytopttei: Eves E]No des oie catsin ar) So ja t.ump sunt cash ee cs: om vs espe Datyca ® OOOOOOO ‘ssstarcm ® OoOoooog] 2 Wnt ten ee: = DODO OOO «cine: fs ODIO | ose reeteresiain verrcneniateteowen's QOOOOOO vo OOO» OOOOOOd | § liege D benrsPreretc Teta ® DODO | 6 oes DDETALS OF BLS ENCLOSED: Sime | BiINe ued by ‘Aout TS TTT NCS NCS DECLARATION BY THE INSURED: hereby decte that “uapressn oreonealnent of ary materal net my rata cain reimbureemer ‘Annexure - cf my kroutadge abet have made ay fle or uns statement ‘alle orieted alo consent & authorize TPA inuranee company, sea necessa7y sé onthe parson sane! warn is lin is ade, hereby detare ta! have Irluded alltel recipi forthe purpose ols cam & at wl rate making ary supplemeriary cam exceat th arepor-nestaiatin ea #8. «EE Oa [DD Pece | sara tte sue ‘GUIDANCE FOR FILLING GLAM FORM PART A(T be filedin by he Inewea) ‘SECTION A- DETAILS OF PRIMARY INSURED a Paley rir the poy number Beale bythe houranee coneary 2) _SLNo! Conieate No niet soil Insrarc8 TURBO Oe CORTES TOT scealnealtinsraneeseheme ‘As aleted by the egeizaion e056 PATER ae ToT By TRO Sr briniadin TPA dooumont ome riers adeess Trclude Suet Cty and Pa Code 3 Cae EoeT0 BY A OAT STITT HAT Teens whore caver covered By arabe Wed 2) CompanyName Erie ul rae ofthe maureen coma Nene othe orgaizaton nl Poteye Enirthepeey number ‘alt bythe rsuranen coma Sum are Ener ol sim eurod as porte bole Tripees ate Erie da of hosptalaton Use many toa Diagrase rire deghess dtals Open Text I Previa Covers By any aar MOGCRAT Heal | Teeate whether provevaly covered by arate MEGERTAT —|riex vor orn Inswanes? Heals surance TL Cameany Name Name Erie ul name ofthe pallet Surname, Fat name, Male nae 3) Gender Treat Gender ofthe patient Tick Wele or Female ci Enier age ote plot Number of wars and one 2) Reatenshipia inary haured Treaterelatnshipo paler wih oaleyolae Tick igh opto, ahes ease sped i) Oeevpaton Teese eeeupaon of patent Tick gh option Wotar, oleae sec a Aeros Erie te ullpestalaaeoss Tpclude Suet Gyan Pa Code hy Phone Ne Enierthe shone nob of aon Treluge STO code wih lphone nob 1 Ema Eniere-nalederess of pation Copies esi saee35 ‘SECTION D- DETAILS OF HOSPITALIZATION are of Howat where sae Erie ware of hpi Tae of Faspre n 2) Room extopry ocepied Treats ho room category occupied ei Horeitateaten au Teese razor of spialiaton| “FDala of FjuyDate Daeave Wat erected Dale Use dy format Toe niet of adieion ‘se hen ora One of dearer Erie die of ena Use dry format Tick ah anton Mek eg Treats whether ity mode egal Tick Ves or No Feperedto Pelco Tres whether poles report was ed TiekYororNo MLC Ropon& Pelee Fi aachod Teese whorer WLC repr ara Poti FIR aero Open Tew SECTION E- DETAILS OF CLAIM @_Dealsal Teamen Expenses riers amount med as testmert amperes Trrupees (Do rot eter pave value) 2) him for Doin Hesprazaton Tren whether nm for dora sphaliafon Tiek Yor orNo_ =\_Detl of Lump son ens bert eaimed niet amount chimed a mp sum eng bone Treate whieh svppoing dbeurens are subried Tek igh apton ‘SECTION F- DETAILS OF BILLS ENCLOSED Tndale Wilh bill are onclosed wah ihe GmGusEs NVUDoee MH NOWLO3S

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