Employee Travel Insurance Claim
Employee Travel Insurance Claim
Claimant Information
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Full Name: [Your Name]
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Employee ID: 654321
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Date of Birth: February 20, 2028
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Address: 123 Future Road, Utopia City, CA 90001
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Phone Number: (555) 123-9876
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Email: [Your Email]
Employer Information
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Company Name: [Your Company Name]
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Company Address: [Your Company Address]
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Company Phone Number: [Your Company Number]
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Company Phone Email: [Your Company Email]
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Supervisor Name: John Smith
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Supervisor Email: [email protected]
Travel Information
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Travel Destination: Tokyo, Japan
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Purpose of Travel: Business Conference
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Departure Date: June 1, 2052
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Return Date: June 10, 2052
Incident Details
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Date of Incident: June 5, 2052
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Time of Incident: 11:00 AM
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Location of Incident: Hotel Metropolis, Tokyo
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Description of Incident: The claimant slipped in the hotel lobby, resulting in a fractured left ankle. Immediate medical attention was required.
Medical Treatment Information
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Initial Medical Treatment Date: June 5, 2052
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Treating Physician Name: Dr. Akira Yamamoto
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Hospital/Clinic Name: Tokyo Central Hospital
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Hospital/Clinic Address: 789 Healthway, Tokyo, Japan
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Phone Number: +81 3-1234-5678
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Description of Treatment: X-rays confirmed a fracture. The ankle was immobilized, and pain medication was prescribed. Follow-up visits and a potential surgery were recommended.
Claim Information
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Claim Number: 987654321
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Type of Incident: Accidental Injury
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Body Part Affected: Left Ankle
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Estimated Medical Expenses: $3,500
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Additional Expenses: $500 (for changes in travel arrangements)
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Total Claimed Amount: $4,000
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Additional Notes: The claimant had to extend the stay for medical treatment, incurring additional hotel and meal expenses.
Signature and Acknowledgement
I hereby certify that the above information is true and accurate to the best of my knowledge. I understand that providing false information can result in denial of my claim and potential legal action.
[Supervisor's Name]
[Your Name]
