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Get Allstate Insurance Template 2020-2024

WELLNESS EXAM Please attach the physician clinic or facility receipt showing the specific wellness exam performed and date it was provided. Thank You. AWD10367-1 1 of 2 5/08 Important To avoid delay please sign authorization below. I authorize any physician medical practitioner hospital clinic or other medical facility insurance company the Medical Information Bureau or other organization institution or person that has records or knowledge of me .

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