Claim Application Form

XX Insurance Company

My name is XXX, age His arm was injured while playing basketball and he was sent to the hospital for treatment and has since recovered.

While I was in the hospital, I spent XXX yuan in medical expenses. Since I applied for your insurance, policy number XXXX and insurance name XXXX, I would like to submit a claim application and hope it will be accepted.

Sincerely

Applicant XXX < /p>

Year, Month, Day