Long-Term Care Insurance Claim
Long-Term Care Insurance Claim
Policyholder Information
Policyholder Name: [Your Name]
Policy Number: ACD24563
Email: [Your Email]
Details of Long-Term Care Services
-
Type of Service: In-home care
-
Name of Care Provider: Comfort Care Home Services
-
Service Start Date: January 1, 2050
-
Service End Date: June 30, 2050
-
Total Cost: $15,000
Nature of Assistance Required
The insured requires continuous assistance with Activities of Daily Living (ADLs) including but not limited to:
-
Bathing
-
Dressing
-
Eating
-
Maintaining continence
-
Transferring (e.g., from bed to chair)
-
Toileting
Supporting Documentation
Please find enclosed the following documents to support this claim:
-
Signed statement from the attending physician
-
Detailed invoices and receipts of care services
-
Care provider's license or certification
-
Policyholder's identification
-
Any additional relevant medical records
Summary of Costs
|
Service Type |
Provider Name |
Date Range |
Total Cost |
|---|---|---|---|
|
In-home Care |
Comfort Care Home Services |
01/1/2050 - 30/6/2050 |
$15,000 |
Declaration
I, [Your Name], hereby declare that the information provided in this claim is accurate and true to the best of my knowledge. I authorize the insurance company to contact my care provider(s) for verification purposes.
[YOUR NAME]
[DATE SIGNED]
