I hereby declare that I am in good health and do not suffer from any incapacity or disability, and that I am not under treatment for any illness of an evolutive nature or likely to cause a relapse. I declare that I have not recently received any medical treatment and do not plan to undergo treatment in the country of stay during the period of the policy.
Any reticence or intentional false declaration which may change the object of the risk or diminish its assessment for the insurers shall result in the nullity of cover. In this case, premiums will not be paid back (Art. L. 113.8 of the insurance Code) |
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| I authorise the practitioners to supply the consulting physician will all necessary information under confidential letter. |
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| I undertake to pay AIPS any amount that shall be refunded to me by my mutual or welfare organization. |
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