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 malf...
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
T2491 v.03 11.06.2017. Page . 1. of . 8. 01-CA9674 H. SETTLEMENT REGISTRATION/CLAIM FORM. Auto Airbag Settlement for
Denplan Corporate claim form To help us settle your claim quickly please complete all sections as accurately as you can. ... Denplan Corporate, Denplan Ltd,
SUBSCRIBER INFORMATION Primary Participant ID# (required) Company Employee Number (if appropriate) Plan Sponsor Last Name First Name Middle Initial
OTHER COVERAGE. Statement of Actual Services – OR –. Request for Predetermination / Preauthorization ... 40. Is Treatment for Orthodontics? Provider's Office. Hospital. ECF. Other. 45. Treatment Resulting from (Check applicable box). 47. Auto Acciden
Chapter 2: 837 Professional Health Care Claim . BCBSNC Companion Guide to X12 5010 transactions – 837 Professional Health Care Claim v.3.4 2
insurance claim… Claim MANUAL preparation. CLAIM PREPARATION MANUAL 1 ... Descriptions of work performed, services purchased or materials expenses that are incurred
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
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
APPLICATION FOR DEATH CLAIM Fund Region Fund Number Council Number For office use only Final contributions WKS@R From To Dated WKS@R From To Dated
DVA Rehabilitation & Compensation Claim Checklist This checklist will help you make sure you haven’t missed anything before you submit your claim:
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
Denplan claim form To help us settle ... Denplan Corporate, Denplan Court, ... please make sure this is clearly stated on this claim form and your itemised receipt
Aetna International Claim Form . Please submit this completed claim form with itemized bills and receipts. A separate claim form is needed for each family
Zurich Australian Insurance Limited ABN 13 000 296 640, AFS Licence No. 232507. 5 Blue Street North Sydney NSW 2060. General Claim Form – Page 1 of 4. General. Claim form. ZU07392 - V3 03/14 - CW. AN-006478-2012. All relevant sections are to be answe
or your tenant, or related to you, give full details werknemer, ‘n huurder of ‘n familielied is, meld besonderhede Claim If a claim has been, or is being
Download GLOBE GADGET CARE. CLAIM FORM. Important Information. 1. In order to submit your claim, please complete the relevant sections. This first page must be ...
Date of birth DDDDDDDD . Dental claim form . Bu Please ensure that you complete this form fully and return it to us with copies or uploads of your original receipts
workers compensation – first report of injury or illness employer (name & address incl zip) insured report number osha log number
Kevin McCarty, Commissioner. 200 E. Gaines St., Room 101A. Tallahassee 32399. 850-413-3140. GEORGIA. Ralph T. Hudgens, Commissioner. 2 Martin Luther King, Jr. Dr. 704 West Tower, Atlanta 30334. 404-656-2070. GUAM. Artemio B. Illagan, Commissioner. P.
National Health Insurance Company – Daman ... Reimbursement Claim Form ... healthcare services provided to me during the period of my insurance coverage with Daman
claim management for disability, ... out on a disability claim. ... expenses, your medical leave,
PLEASE READ BEFORE COMPLETING THE CLAIM FORM ‘ All claim forms should be submitted ... completed this form please post it to: Denplan Corporate Denplan Court
MEDICAL EXPENSE REIMBURSEMENT ACCOUNT CLAIM ... If you are a member of a group plan that ... Complete and sign the Medical Expense Reimbursement Account Claim form
FAX TO 1-866-302-8408 Claims Documentation Processing 648 Grassmere Park Dr. – Suite 200 Nashville, TN 37211
CLAIM AFFIDAVIT A person who knowingly presents a false or fraudulent insurance claim for coverage of a loss is guilty of a crime and may be subject to fines and confinement in state prison. When fraud is discovered, Asurion takes appropriate steps to stop such fraud and explore all of its available legal remedies. 4 STEPS TO COMPLETING THE FILING OF YOUR CLAIM: 1. FILL OUT THIS FORM COMPLETELY (FAILURE TO DO SO MAY RESULT IN A DELAY IN THE PROCESSING OF YOUR CLAIM) 2. THE INSURED PARTY MUST SIGN THIS FORM IN THE PRESENCE OF A NOTARY 3. ATTACH A COPY OF A GOVERNMENT ISSUED PHOTO IDENTIFICATION (SEE BELOW FOR ACCEPTABLE ID’S) 4. RETURN COMPLETED FORM TO ASURION AT THE ABOVE ADDRESS, OR FAX TO 1-866-302-8408
Section I: Claimant Information Claim ID:
Wireless Phone #
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Wireless Carrier: Alltel
Insured’s First Name:
Insured’s Last Name::
Daytime Phone Number:
Evening Phone Number:
Address: City:
State:
Zip Code:
Section II: Describe Wireless Equipment & Loss Manufacturer:
Model Number:
(ie, Motorola, Nokia, Audiovox, etc)
(ie, V400, 7610, 2500 etc)
Check one - The phone was…..
Lost _____
Stolen _____
Date of Loss/Incident:
Place of Loss/Incident:
Damaged _____
Just Stopped Working _______
Provide detailed description of the cause of loss or damage:
Section III: Please Attach a Copy of a Government Issued Photo ID Type of Photo ID:
Drivers License _____
Passport/Visa _____
Military _____
Other State-issued ID ______
ID Number:
I swear that the wireless phone I am claiming is owned by me and is on file with Alltel and that the information provided above is true and accurate. I understand that any false or misleading statement herein is fraud and I may be found guilty of a crime. I hereby make claim against the insurance company as shown on this Claim Affidavit. I agree if the phone is damaged or malfunctioning to return it to the Alltel store upon receipt of the replacement phone. I further agree that if any property included in this claim that is replaced or paid for by the Insurer is recovered at any time, it shall become the property of the insurance company and shall be returned to Asurion. I understand that if I fail to return such property, I will owe a non-return fee of up to $300 to the insurance company. To eliminate and prevent future fraudulently filed claims, Asurion examines all phones when they are returned. If I have claimed a malfunctioning phone and rather my phone is found to no longer function due to damage, I will owe the required deductible as provided for in the policy. I understand that damage claims under the insurance program have higher deductibles than malfunction claims under the warranty program. Insured – Print Name
SUBSCRIBED AND SWORN TO BEFORE ME ON THIS DAY OF
INSURED SIGNATURE
DATE
20
NOTARY SIGNATURE: NOTARY PHONE NUMBER:
THE INSURED PARTY MUST SIGN THIS FORM IN THE PRESENCE OF A NOTARY. ONCE NOTARIZED, THIS STATEMENT BECOMES A LEGALLY BINDING DOCUMENT.
