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Get Card Purchase Insurance Claim Form

Of liability nor as a waiver by the Company of any breach of the policy conditions. (You are required to enclose copies of your charge slip, bills and statement of account from the Bank with this form.) Name of Claimant in full: Occupation: Address: Telephone No: Residence: Card Company: Type of Card: Expiry Date of Card: Mobile: Card Account No: Date, time and place of accident/loss: State how the accident/loss occurred: (note that it is necessary that the fullest particulars be given.

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