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:
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]
Insurance Claim Templates @ Template.net
