John Hancock Independent Care Provider Service Reimbursement Completed Form Examples and Samples
View a detailed example of a completed John Hancock Independent Care Provider Service Reimbursement form. This free sample demonstrates how to accurately fill out the claim for in-home care, helping you submit your long-term care insurance paperwork correctly.
John Hancock Independent Care Provider Service Reimbursement Example
How this form was filled:
This is an example of a completed John Hancock Independent Care Provider Service Reimbursement form. It is submitted by a Power of Attorney on behalf of the insured for in-home personal care services provided by a licensed independent caregiver for the month of March 2026. The form details the provider's information, services rendered, hours, rates, and includes required signatures.
Information used to fill out the document:
- Insured's Full Name: Eleanor Vance
- Insured's Policy Number: JH-LTC-987654321
- Insured's Date of Birth: 05/10/1946
- Insured's Address: 456 Oak Avenue, Anytown, USA 12345
- Submitter's Name (if not Insured): Sarah Miller
- Submitter's Relationship to Insured: Daughter / Power of Attorney
- Care Provider's Name: Maria Garcia
- Provider's Professional Title/License: Licensed Practical Nurse (LPN)
- Provider's Tax ID Number: 98-7654321
- Provider's Address: 101 Maple Drive, Anytown, USA 12345
- Service Period: 03/01/2026 to 03/31/2026
- Types of Services Provided: Personal Care (Bathing, Dressing, Toileting), Medication Reminders
- Total Days of Care: 31
- Hours of Care Per Day: 4
- Provider's Hourly Rate: $30.00
- Total Reimbursement Claimed: $3,720.00
- Date of Submission: 04/05/2026
What this filled form sample shows:
- Clearly defined insured and submitter (Power of Attorney) information.
- Complete care provider details, including professional license and Tax ID.
- Detailed log of services rendered and calculation of total cost.
- Properly dated signatures from both the provider and the insured's representative to validate the claim.
Form specifications and details:
| Form Name: | John Hancock Independent Care Provider Service Reimbursement |
| Use Case: | Claim for in-home care by a non-agency, licensed caregiver. |
| Submitted by: | Power of Attorney for the insured. |
| Filing Period: | Monthly |
Created: February 26, 2026 09:09 PM
