Tuition Insurance Claim
Tuition Insurance Claim
Claimant Information
|
Name: |
[Your Name] |
|
Address: |
123 Maple Street, Springfield, IL 62704 |
|
Phone Number: |
(555) 123-4567 |
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Email Address: |
[Your Email] |
Policy Information
|
Field |
Details |
|---|---|
|
Insurance Policy Number: |
TU123456789 |
|
Insurance Provider: |
Secure Education Insurance |
|
Policyholder Name: |
[Your Name] |
Reason for Claim
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Reason for Withdrawal: Medical Emergency
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Detailed Explanation: Due to a recent diagnosis of a chronic illness, I am unable to continue my studies at Springfield University for the current semester. Medical documentation confirms the necessity for extended treatment and recovery time.
Supporting Documentation
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Medical Records/Doctor’s Note
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Academic Withdrawal Form
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Hospital Admission Summary
Financial Information
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Total Tuition Paid: $10,000
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Amount Claimed: $5,000
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Payment Method: Credit Card
Signature and Declaration
I hereby declare that the information provided is true to the best of my knowledge. I authorize the insurance company to verify the information and process the claim.
[Your Name]
[Date]
