Tuition Insurance Claim
Claimant Information
Name: | [Your Name] |
Address: | 123 Maple Street, Springfield, IL 62704 |
Phone Number: | (555) 123-4567 |
Email Address: | [Your Email] |
Policy Information
Field | Details |
|---|
Insurance Policy Number: | TU123456789 |
Insurance Provider: | Secure Education Insurance |
Policyholder Name: | [Your Name] |
Reason for Claim
Reason for Withdrawal: Medical Emergency
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
Financial Information
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]
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