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HEALTH INSURANCE Claimed be filled in by the insurer Claim case No. Registration place Submission date Claim registered by policyholder Name Data of insured person First name, surname Identity Number

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What is to be filled in?

The form name or information required will be filled in.

Who is required to file to be filled in?

The individuals or entities specified in the instructions are required to file.

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The purpose of the form is to collect specific information for reporting or compliance purposes.

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Information relevant to the specific form requirements must be reported.

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