Education Insurance Claim
Education Insurance Claim
I. Policyholder Information
"Please fill out the following information"
|
Name: |
[Your Name] |
|
Policy Number: |
ED12345678 |
|
Email Address: |
john.doe@example.com |
|
Phone Number: |
(123) 456-7890 |
II. Beneficiary Details
"Please fill out the following information"
|
Name: |
Jane Doe |
|
Relationship to Policyholder: |
Daughter |
|
Date of Birth: |
January 1, 2050 |
|
Email Address: |
jane.doe@example.com |
|
Phone Number: |
(987) 654-3210 |
III. Claim Details
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Event: Policyholder's Disability
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Date of Event: March 15, 2063
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Description: Policyholder suffered a severe accident leading to permanent disability, making it impossible to continue employment and support educational expenses.
IV. Claim Amount
|
Expense Category |
Amount (USD) |
|---|---|
|
Tuition Fees |
$15,000 |
|
Accommodation |
$8,000 |
|
Books |
$2,000 |
|
Other Educational Expenses |
$1,000 |
|
Total |
$26,000 |
V. Support Documentation
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A medical report confirming disability
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Tuition fee invoice from the educational institution
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Accommodation receipts
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Receipts for books and other educational expenses
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Policy document
VI. Declaration and Authorization
I, [Your Name], hereby declare that the information provided in this claim is accurate and complete to the best of my knowledge. I authorize the insurance company to verify the information provided and to contact the relevant medical and educational institutions as necessary to process this claim.
VII. Signature
[Your Name]
[Date Signed]
