I,. of full age, being duly sworn, according to law, upon my oath depose and say that: 1. On or about. , I lived at: Street Address: Floor or Apartmen...
Gender is _____Male _____Female. 7. a. _____ I am not a Medicare beneficiary b. _____ I am a Medicare beneficiary and my Health Insurance Claim Number (“ HICN”) is . 8. My driver's license information is : State ______ Number . 9. On. , the date the
AFFIDAVIT OF NO INSURANCE ... (Name/Address of Owner/Operator). As a result of this accident, I sustained personal injury. On the above date, I did not own or ... I understand that any person who knowingly files a statement of claim containing any fa
Date of Loss/Incident: ... I hereby make claim against the insurance company as shown on this Claim Affidavit. I agree if the phone is damaged or malfunctioning to
FLORIDA INSURANCE AFFIDAVIT Under penalty of perjury, I _____ certify that I have (Name of Insured) Personal Injury Protection
Payee NRIC: Bank Account No:: Notification of payment will be sent to this email address. Important Notice: The Company shall (i) be discharged from all liability
AFFIDAVIT OF VEHICLE THEFT. Page 1 of 5. All questions must be answered. Please print. Claim Number. Name of Insured. Home Phone. Cell Phone. Social Security ... Monetary estimate of vehicle damage. Specific location ... Name and address of insurance
Department of Industrial Accidents. Office of Investigations. 600 Washington Street. Boston ... Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ‡Co
Was Vehicle locked? Yes No. Date and time vehicle parked there: Who left the vehicle at that location: If other than policyholder, Did they have permission to take the vehicle: Yes No. Describe: Who discovered the theft: Name: Their driver's licence
PLEASE MAIL CLAIMS TO: United HealthCare Insurance Company of New York P.O. Box 1600 Kingston, New York 12402-1600 1-877-7NYSHIP (1-877-769-7447)
PICA B. PLACE OF SERVICE 1a. INSURED’S I.D. NUMBER (For Program in Item 1) 4. INSURED’S NAME (Last Name, First Name, Middle Initial) 7. INSURED’S ADDRESS (No
CONTINENTAL AMERICAN INSURANCE COMPANY CLAIM FORM Post Office Box 427 Email: [email protected] . Columbia, South Carolina 29202 Phone (800)433-3036 Fax (803)799-7737
c) The damaged vehicle must be parked at safe place to avoid any subsequent damage/loss. Bajaj Allianz General Insurance ... Statement to describe circumstances leading to an accident \ theft [please also specifically mention the location of accident
Your Payment Protection Insurance Claim (PPI) ± Client Care Letter In this letter we have set out the instructions you have given to us and explain the basis upon
CONTINENTAL AMERICAN INSURANCE COMPANY CLAIM FORM Post Office Box 427 • Columbia, South Carolina 29202 • Phone (800) 433-3036 Fax (866) 849-2970
Payee NRIC: Bank Account No:: Notification of payment will be sent to this email address. Important Notice: The Company shall (i) be discharged from all liability
BORANG TUNTUTAN INSURANS PERJALANAN ... Alamat Surat Menyurat ... Pembatalan Perjalanan Medical report Laporan perubatan
Part C. Your Certification Statement of Claim — Option C Family Life Insurance Federal Employees’ Group Life Insurance (FEGLI) Part A. Information about You
I/We hereby agree, affirm and declare that : a. The statements/information given/stated by me, us in this claim form are true, corrected and complete
COLORADO—AFTER THE FIRE Your Step-by-Step Home Insurance Claim Recovery Guide If you have lost your home or suffered damage to your home or personal belongings as
Group life claim fraud statements Alaska:A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim
Feb 21, 2011 ... encountered on the project in this forum. However, I am satisfied that because the Claimant was responsible for part of those delays, it ought not be able to recover the liquidated damages claimed or any part thereof. The “Minor Vari
AHCA Form # 3100-0008, August 2010 Section 59A-35.090(3)(b)2, Florida Administrative Code Page 1 of 3
CITY OF PHILADELPHIA. RISK MANAGEMENT DIVISION - CLAIMS UNIT. 1515 ARCH STREET ... DATE OF BIRTH: SOCIAL SECURITY NUMBER: DATE AND TIME OF THE ACCIDENT/INCIDENT: ... THE CITY WILL PROVIDE AN AFFIDAVIT OF NO INSURANCE TO BE NOTARIZED. AFTER SUBMITTING
DE 2501 Rev. 79 (10-16) (INTERNET) Page 1 of 7. 250110161. Claim for Disability Insurance (DI) Benefits . Health Insurance Portability and Accountability Act (HIPAA
PO Box 900 Lincroft, NJ 07738
High Point Preferred Insurance Company High Point Safety and Insurance Company High Point Property and Casualty Insurance Company Palisades Safety and Insurance Association Palisades Insurance Company Palisades Property and Casualty Insurance Company
AFFIDAVIT OF NO INSURANCE Claimant:
Claim Number:
Insured:
Date of Loss:
Policy Number: I, ______________________________________ of full age, being duly sworn, according to law, upon my oath depose and say that: 1. On or about ________________________________________, I lived at: Street Address: Floor or Apartment: City: State: Zip: 2. I was injured in an accident involving a private passenger automobile. 3. I was not the owner of an automobile, nor did any relative in my household own an automobile. I was not the holder of any Automobile Liability Insurance, nor was any relative in my household the holder of any Automobile Liability Insurance. 4. To the best of my knowledge, I am not otherwise entitled to New Jersey Automobile No-Fault benefits for this accident. 5. My date of birth is: Social Security Number: Driver's License Number: Home Phone Number: Business Phone Number: 6. List all members in the household. If no one lives with you indicate "NONE": Name (Last,First) Date of Birth
Relationship
This form must be notarized by a duly authorized Notary Public and returned to this office prior to the application of benefit. Signed: _________________________________________________ For Notary Use Only Subscribed and sworn to me this State of
