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1 January 2015 Claim form for medical treatment reimbursements Please complete clearly in BLOCK CAPITALS. Are you submitting this claim as a scanned copy? Yes No One form must be completed for each

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5. Use a black or blue ink pen: If you are filling out the form by hand, use a black or blue ink pen to ensure the clarity of your answers. Avoid using pencils or colored pens that may smudge or fade over time.

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