Disability Insurance Claim

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Claimant Information

Name:	[Your Name]
Email:	[Your Email]
Policy Number:	AVB24652

Medical History

Please find below the detailed medical history relevant to the disabling condition:

• Condition: Chronic Back Pain

• Date of Diagnosis: June 15, 2050

• Treatments Received:

  • Physical Therapy

  • Medication

  • Spinal Injections

Impact on Work Ability

The disabling condition significantly impairs the claimant's ability to perform job duties, as described below:

Job Title:	Software Engineer
Employer:	[Your Company Name]
Primary Duties:	Programming, Code Review, Team Meetings
Limitations:	Unable to sit for prolonged periods, difficulty concentrating due to pain, frequent medical appointments

Claim Request

The claimant respectfully requests the following benefits as per the terms of the disability insurance policy:

• Monthly Disability Benefit Payments

• Coverage of Medical Expenses

• Rehabilitation Support

Supporting Documentation

The following documents are attached to support this claim:

• Medical Reports from Dr. Jane Smith

• Physical Therapy Records

• Employer's Statement

• Claimant's Statement

Claimant's Declaration

I, [Your Name], hereby affirm that the information provided in this insurance claim is accurate and complete to the best of my knowledge. I acknowledge that any misrepresentation or false information may result in the denial of my claim or other legal consequences.

[YOUR NAME]

[DATE SIGNED]

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