Modello dichiarazione art 142 cod assicurazioni private

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  • 1. Assicurato (Nome / Cognome)Via …………………….……………………………….Tel. ………………………….Fax ……………………….Email: ………………………………. Spett.le ………………………….. ………………………….. ………………………….. …………………………..Oggetto: Sinistro n° ……………………….. del __/__/_______ – DichiarazioneIo sottoscritto ……………….., C.F. ……………………………… in relazione al sinistro in oggetto, DICHIAROex art. 142 D. Lgs. N. 209 del 7 Settembre 2005, di non avere diritto a prestazioni da parte di enti gestori diassicurazioni sociali obbligatorie.[Luogo], 6 February 2013 Firma ___________________________