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Request insurance
Please full fill this form with all correct informations. If any information is not correct. We will decline your insurance
Username (your email if the email used to login) *
Password *
Deposit date *
MM
/
DD
/
YYYY
Amount deposit *
Amount RCB paid (Include Bonus) *
Amount withdrawn *
Perfectmoney wallet (Please contact insurance staff if you use other payments) *
Telegram - @username (If we can not contact you via telegram, we will decline your insurance) *
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