Gender is _____Male _____Female. 7. a. _____ I am not a Medicare beneficiary b. _____ I am a Medicare beneficiary and my Health Insurance Claim 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
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
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
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
Keyboard Arrangements of Music by Jean-Baptiste Lully, ed. David Chung, 2014 List of Sources, p. i List of Sources List A: Major Sources List A covers the major
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
World's Bird Species.pdf [PDF] Gluten-Free Salads: A Beginner's Guide To Seriously Delicious Salads. Look Great, Feel Better.: Gluten Free.pdf [PDF] My EDS Journey
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
Life Insurance Corporation of India FORM NO.300(Rev 02) We Know India Better Page 4 of 7 Wife/Husband Children
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)
Part C. Your Certification Statement of Claim — Option C Family Life Insurance Federal Employees’ Group Life Insurance (FEGLI) Part A. Information about You
113 Renewable Sources of Energy-I Notes MODULE - 8B Energy Conservation 2. Give three examples of conventional and non-conventional sources of ener gy
certificate and affidavit of satisfaction . commonwealth of virginia . va. code §§ 55-66.3 to 55-66.6
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
If searched for the ebook by Pietro Mascagni Cavalleria rusticana (No, no Turridu, rimani [to end of duet] (soprano, tenor)): Full Score (Qty 2) [A3564] in pdf format
Medicare Secondary Payer (MSP) Liability Insurance, No-Fault Insurance & Workers’ Compensation Recovery Process Note: This presentation is intended for Medicare
Section A: Multiple-Choice Questions. Question 1. For the following multiple- choice questions, fill in the circle of the letter that identifies the most correct answer. DO NOT MARK THE ANSWERS ON THESE PAGES. USE THE FIRST PAGE OF YOUR ANSWER BOOK.
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
NEW BUSINESS REPORT ON MEETING WITH DIVISION OF ACADEMIC FACILITIES Dr. Moody told the board that he, Mrs. Holt, Terry Cooper, and Lara Cooper met with Doug Eaton,
Claim No.:___________________ AFFIDAVIT OF NO OTHER SOURCES OF INSURANCE State of:_____________________ County of:__________________________________ I, ________________________________ of full age, being duly sworn according to law, on his/her oath says: 1.
I currently reside at __________________________________________________and have done so since ______________________________________.
2.
My home phone number is ___________________________________.
3.
My date of birth (“DOB”) is __________________________________.
4.
My social security number (“SSN”) is __________________________. (if none, enter “none”)
5.
My Individual Taxpayer Identification number (“ITIN”) is __________________________. (if none, enter “none”)
6. 7.
Gender is _____Male _____Female 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 accident occurred: a. I resided at __________________________________________________________________. b. If my driver’s license was different that in (7) above, it was: i. State _____ Number___________________________________________________. c. Other residents of my household on the date the accident occurred were:
i. Name _____________________DOB________________SSN__________________ Driver’s License # _______________________________State__________________ Their relationship to you ________________________________________________ ii. Name _____________________DOB________________SSN__________________ Driver’s License # _______________________________State__________________ Their relationship to you ________________________________________________ iii. Name _____________________DOB________________SSN__________________ Driver’s License # _______________________________State__________________ Their relationship to you ________________________________________________ (Attached additional sheet, if necessary.) Check all that apply below: 10. _____On___________________, the date the accident occurred, I was not a resident of a household wherein any resident was the registered owner of a motor vehicle covered by a policy issued by an insurance company. 11. _____On___________________, the date the accident occurred, I was not insured by any medical insurance carrier for coverage of medical services. 12. _____On___________________, the date the accident occurred, I personally did not own an automobile with liability insurance coverage that would afford me Personal Injury Protection/No-Fault benefits. I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statement made by me are willfully false, I am subject to punishment.
______________________________ Signature
Sworn to and subscribed before me this _____day of _____________, 20____.
