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Surgical intervention recommended by Doctor
I, the undersigned Mr / Mrs
hereby declare that all the information given above is true to my knowledge, and that I have neither retained nor concealed any information
regarding the claim put forward. I am fully aware that all false declaration and/or non-disclosure of material facts shall render this claim null and
void and will entail the termination of the contractI authorise RPL Insurance Agency to contact my treating doctor in respect of any complementary information required in relation
to my illness or treatment received in relation to the claim and as regards my medical history and also authorise that these information be
communicated to RPL Insurance Agency.
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