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Hospital Insurance Policy Application Form

Section 1: Applicant Information

Section 2: Contact Information

Section 3: Insurance Coverage Details

Section 4: Dependent Information (if applicable)

Section 5: Medical History

Section 6: Current Insurance Information

Section 7: Authorization and Declaration

I hereby certify that all the information provided above is true and complete to the best of my knowledge. I understand that any misrepresentation may result in denial or cancellation of coverage. I authorize the insurance company to verify any of the above information.

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