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I hereby certify that all information on this form and its supporting documentation is true
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__________________________________
Claimant's Signature
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__________________________________
Claimant's Name
(printed):
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____________________
Date
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Please note: All requests missing checklist items will be denied due to missing
information. Please send
all claim requests and supporting documentation to:
ICS Courier CLAIMS DEPT, 81 avenue Lindsay, Dorval, PQ H9P 2S6 OR Fax to
1-866-748-1029
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