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Details of Insured

Policy Number

Full Name

Address

District

Town

Post Code

Email Address

Phone Number

Details of Claim (or potential claim)

Claim Type

Delarations

The information and answers given above are true, correct and complete in every detail.

I understand the claim may be refused if information is not true or is withheld.

The Pharmacy Insurance Agency Limited is registered in England and Wales under company number 2591975
It is authorised and regulated by the Financial Conduct Authority (Register No 307063)

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