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5/13/2018 Formulario 6004 sctr essalud
1/5
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DISTRIBUCION GRATUITA ~PROHIBIDA SU VENTA
Formulario IN 00 0710 511)
6004 ~EsSaiUd usa EsSaludLaTE I FallaI
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usa EsSalud
MAS S,~LUD PARA Mf\.S FERUANQS
Seguro Complementario deTrabajo de Resgo
INDEPENDIENTES
( _ ~ _ ~ _ ~ _ ~ _ ~ _ ~ _ R _ A _ ~ _ o ~ I ~ J F e c h a d elnscripc.on DIA I MES I ANaCODIGO DE ACTIVIDADD E RIESGO (GIIU). ( I I I I J
5E DATOSDELTITULAR5aI:. .:d
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