Cosmopolitan Health Insurance

East Legon - Greater Accra
info@cosmopolitanmhi.com

Company Name

Contact Number of Main Member

Cheque Should Be Written In The Name Of

Upload Supporting Documents (Receipts and Prescriptions)

Reason for Refund

Member Refund

Member Name

Policy Number

Amount (GH¢)

Facility Name

Date Visited

Declaration

I hereby declare that the information provided is true to the best of my knowledge.
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