/ / / / 3. Did the traumatic event(s) occur within the 48 hours before the worsening of ischaemic heart disease?  No  Yes - Please provide details of the traumatic event(s), and describe the worsening effect on the ischaemic heart disease: Date on the Description of traumatic event Worsening effect on traumatic event occurred ischaemic heart disease / / / / Claimant's Signature You are reminded that: The Declaration you signed on the claim form also covers the information you supply on this form. There are penalties for knowingly making false or misleading statements. / /
/ / / / 3. Did the traumatic event(s) occur within the 48 hours before the worsening of ischaemic heart disease?  No  Yes - Please provide details of the traumatic event(s), and describe the worsening effect on the ischaemic heart disease: Date on the traumatic event occurred Description of traumatic event Worsening effect on ischaemic heart disease / / / / Claimant's Signature You are reminded that: The Declaration you signed on the claim form also covers the information you supply on this form. There are penalties for knowingly making false or misleading statements. / /
CR9142_1.docx