Employee Travel Insurance Claim
Claimant Information
Full Name: [Your Name]
Employee ID: 654321
Date of Birth: February 20, 2028
Address: 123 Future Road, Utopia City, CA 90001
Phone Number: (555) 123-9876
Email: [Your Email]
Employer Information
Company Name: [Your Company Name]
Company Address: [Your Company Address]
Company Phone Number: [Your Company Number]
Company Phone Email: [Your Company Email]
Supervisor Name: John Smith
Supervisor Email: john.smith@futurecorp.com
Travel Information
Travel Destination: Tokyo, Japan
Purpose of Travel: Business Conference
Departure Date: June 1, 2052
Return Date: June 10, 2052
Incident Details
Date of Incident: June 5, 2052
Time of Incident: 11:00 AM
Location of Incident: Hotel Metropolis, Tokyo
Description of Incident: The claimant slipped in the hotel lobby, resulting in a fractured left ankle. Immediate medical attention was required.
Medical Treatment Information
Initial Medical Treatment Date: June 5, 2052
Treating Physician Name: Dr. Akira Yamamoto
Hospital/Clinic Name: Tokyo Central Hospital
Hospital/Clinic Address: 789 Healthway, Tokyo, Japan
Phone Number: +81 3-1234-5678
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
Claim Number: 987654321
Type of Incident: Accidental Injury
Body Part Affected: Left Ankle
Estimated Medical Expenses: $3,500
Additional Expenses: $500 (for changes in travel arrangements)
Total Claimed Amount: $4,000
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]
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