This letter requests reimbursement from your insurance company for costs incurred by you.
1234, Main Street
Boston, MA 02123
05 April, 2005
<Recipient Address Goes Here>
Re: Member No. <member number>
Group No. <group number>
Enclosed please find <a receipt/receipts> for <nature of receipts>. I would appreciate it if you would please send me a check for <$amount> to reimburse me for these out of pocket expenses.
Thank you for your attention to this request. If you have any questions about any of these items, please do not hesitate to contact me.
encl: <List of enclosed items goes here>