Disability Insurance Claim
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:
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:
Supporting Documentation
The following documents are attached to support this claim:
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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