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Universal claim form CARDHOLDER NAME L/F/MI 1A4 PLAN NAME OTHER COVERAGE CODE (1) PATIENT NAME L/F/MI PERSON CODE (2) PATIENT (4) RELATIONSHIP CODE FOR OFFICE USE ONLY 1842 - 1108 - 9227M CARDHOLDER I.D. GROUP I.D. Copyright

Cigna dental insurance claim f... Dental Claim Form HEADER INFORMATION 1. Type of Transaction (Mark all applicable boxes) Statement of Actual Services EPSDT/ Title XIX 2. Predetermination / Preauthorization Number Request for Predetermination

Petition small claims form This DESIGNATION OF REPRESENTATIVE TO FILE PETITION as petitioner or officer thereof hereby designate I to act as my representative in any and all proceedings before the Small Claims Assessment Review of the Supreme Court in the assessment of my real property as it appears on the County for purposes of reviewing year assessment roll of Signature of Owner Or officer thereof Date PART V ELIGIBILITY AND CERTIFICATION I certify that d e f The owner has previously filed a complaint required for administrative review of assessments. UCS 900 Rev. March 2007 PETITION SMALL CLAIMS ASSESSMENT REVIEW IN COUNTIES OUTSIDE NEW YORK CITY one petition per parcel RPTL 730 PART 1 GENERAL INFORMATION SUPREME COURT COUNTY OF Filing Calendar Assessing Unit Date of final completion and filing of assessment roll a Total b Exempt amount c Taxable assessed value 3a-3b Date of filing or mailing petition Name of owner or owners of property Post Office Address Telephone If applicable name and address of representative of owner if representative is filing application Owner must complete Designation of Representative section. Description of property as it appears on the assessment roll. Tax Map Section Block Lot Location of property street road highway number and city town or village PART II GROUNDS FOR PETITION A. Assessment requested on the complaint form filed with the Board of Assessment Review B. Total assessment CALCULATION OF EQUALIZED VALUE AND MAXIMUM REDUCTION IN ASSESSMENT Property is NOT in a special assessing unit. ASSESSED VALUE C. EQUALIZATION RATE EQUALIZED VALUE Property IS in a special assessing unit. CLASS ONE RATIO If the EQUALIZED VALUE exceeds 450 000 enter the ASSESSED VALUE here Multiply the ASSESSED VALUE by Enter the result here The result is the maximum total assessment request reduction allowable. x. 25 UNEQUAL ASSESSMENT The total assessment is unequal because the property is assessed at a higher percentage of full market value than check one. a the average of all other property on the assessment roll or b the average of residential property on the assessment roll* Full market value of property Based on one or more of the following petitioner believes this property should be assessed at of full market value The latest State equalization rate for the assessing unit in which the property is located enter latest equalization rate. The latest residential assessment ratio for the assessing unit in which the property is located enter residential assessment ratio A sample of market values of recent sales prices and assessments of comparable residential properties on which petitioner relies for objection list parcels on a separate sheet and attach. Statements of the assessor or other local official that property has been placed on the roll at. This amount may Petitioner believes the total assessment should be reduced to not be less than the total assessment amount indicated in Section A 1 or Section B 3 whichever is greater. D. EXCESSIVE ASSESSMENT The total assessed value exceeds the full market value of the property. Total assessed value of property Complainant believes the total assessment should be reduced to a full value of Attach list of parcels upon which complainant relies for objection if applicable.

Dci tatda claim forms DENTAL COUNCIL OF INDIA NEW DELHI GUIDE LINES FOR PREPARATION OF TA/DA CLAIMS ON TEM. DUTY MOVES Contents Contents respecting TA/DA bill form alongwith guidelines and other required information for

Ej 160 claim of exemption on l... This includes providing spaces for an email address and a fax number. In addition a new item 1 has been added to the Claim of Exemption Wage Garnishment form WG-006 in which to enter the name of the person making the claim. The subsequent items on the form have been renumbered accordingly. This item already exists on Claim of Exemption Enforcement of Judgment form EJ-160 but it has been slightly revised so that the text the item will be identical...

Ups scs customer cargo claim f... UPS-SCS Customer Cargo Claim Form Press F1 on any field for help Claim Amount (specify currency): Is hereby filed for (check one): Date filed: UPS Bill of Lading/Air Waybill No: UPS Bill of Lading/Air

Colorado quit claim deed joint... Prepared By and After Recording Return to: Send Tax Statements to Grantee (Name and Address): --------Above This Line Reserved For Official Use Only-------- QUITCLAIM DEED Individual to Two Individuals

Georgia claim of lien sect44 1... After Recording Return to: CLAIM OF LIEN STATE OF GEORGIA, COUNTY OF LIEN CLAIMANT: , a (mechanic, contractor, subcontractor, materialman, machinist, manufacturer, registered architect, registered

Quit claim deed form individua... This document prepared by (and after recording return to): Name: Firm/Company: Address: Address 2: City, State, Zip: Phone: ) ) ) ) ) ) ) ) ) ) --------Above This Line Reserved For Official Use Only-------------

Quit claim deed georgia form This document prepared by (and after recording return to): Name: Firm/Company: Address: Address 2: City, State, Zip: Phone: ) ) ) ) ) ) ) ) ) ) --------Above This Line Reserved For Official Use Only-------------

Claim form nj NJ DIRECT Claim Form NJ State Health Benefits Program SHBP Please Print This Form In Color If Available. Please write your NJ DIRECT identification number clearly on the first page. CLAIM FORM MAY BE ADDITIONAL INFORMATION IS NOT SUPPLIED HELPFUL HINTS When you are submitting expenses for more than one family member please use a separate claim form for each person. It is suggested that you make copies for your own use before you submit the original bills. WHERE TO SUBMIT YOUR CLAIM FORMS Please mail completed claim form for MEDICAL CLAIMS TO Horizon Blue Cross Blue Shield of New Jersey P. O. Box 820 Newark NJ 07101-0820 MENTAL HEALTH/SUBSTANCE ABUSE CLAIMS TO Magellan/NJ DIRECT PO Box 5172 Columbia MD 21045-5172 FRAUD WARNING ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES TO REPORT SUSPECTED FRAUD CALL 1-800-624-2048 AT HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY. LAST NAME OF SUBSCRIBER 22. SEX 26. HEALTH COVERAGE PLAN NAME OR PROGRAM NAME AUTHORIZATION 27. I certify that the information provided is correct and complete and that I am claiming benefits only for charges actually incurred by the patient named. I authorize any provider who participated in care and treatment to release to Horizon Blue Cross Blue Shield of New Jersey Horizon BCBSNJ all medical or other information requested for the processing of this claim. I agree that New Jersey State auditors NJ State Health Benefits Program and Horizon BCBSNJ may see or get a copy of any such medical records. This information is for the sole use of the New Jersey State Health Benefits Program and Horizon BCBSNJ to administer and analyze the health program. Unless a law requires it information will not be given in an identifiable form to any other persons unless I agree to its release in writing. If you have any questions about how to submit your Claims please call the Customer Service 1-800-414-SHBP 7427. WHERE TO SUBMIT YOUR CLAIM FORMS Please mail completed claim form for MEDICAL CLAIMS TO Horizon Blue Cross Blue Shield of New Jersey P. This information is for the sole use of the New Jersey State Health Benefits Program and Horizon BCBSNJ to administer and analyze the health program. Unless a law requires it information will not be given in an identifiable form to any other persons unless I agree to its release in writing. I agree to reimburse Horizon BCBSNJ should this claim be incorrectly paid. 28. SIGNATURE OF PATIENT unless a minor Spouse Civil Union or Domestic Partner 2642 W0208 DATE SEE BACK OF THIS FORM FOR IMPORTANT INFORMATION An Independent Licensee of the Blue Cross and Blue Shield Association PLEASE READ THIS IMPORTANT INFORMATION WHEN YOU ARE SUBMITTING EXPENSES FOR MORE THAN ONE FAMILY MEMBER PLEASE USE A SEPARATE CLAIM FORM FOR EACH PERSON. ITEMIZED BILLS FOR COVERED SERVICES OR SUPPLIES MUST BE ATTACHED TO THIS FORM AND INCLUDE THE FOLLOWING Check that each itemized bill is legible and contains ALL of the following information NAME ADDRESS of person or institution rendering the service or supplying the item PATIENT S FULL NAME BILLS MISSING ANY OF TYPE of service rendered/produced or item supplied THIS INFORMATION MAY DATE each service rendered or item supplied BE RETURNED TO YOU AMOUNT charged for each service rendered or item supplied DIAGNOSIS of ailment Cash register receipts cancelled checks money order receipts personal itemizations and bills only noting a balance due are not acceptable. I agree to reimburse Horizon BCBSNJ should this claim be incorrectly paid. 28. SIGNATURE OF PATIENT unless a minor Spouse Civil Union or Domestic Partner 2642 W0208 DATE SEE BACK OF THIS FORM FOR IMPORTANT INFORMATION An Independent Licensee of the Blue Cross and Blue Shield Association PLEASE READ THIS IMPORTANT INFORMATION WHEN YOU ARE SUBMITTING EXPENSES FOR MORE THAN ONE FAMILY MEMBER PLEASE USE A SEPARATE CLAIM FORM FOR EACH PERSON. ITEMIZED BILLS FOR COVERED SERVICES OR SUPPLIES MUST BE ATTACHED TO THIS FORM AND INCLUDE THE FOLLOWING Check that each itemized bill is legible and contains ALL of the following information NAME ADDRESS of person or institution rendering the service or supplying the item PATIENT S FULL NAME BILLS MISSING ANY OF TYPE of service rendered/produced or item supplied THIS INFORMATION MAY DATE each service rendered or item supplied BE RETURNED TO YOU AMOUNT charged for each service rendered or item supplied DIAGNOSIS of ailment Cash register receipts cancelled checks money order receipts personal itemizations and bills only noting a balance due are not acceptable. COORDINATION OF BENEFITS If you or your covered dependent s are covered by another health insurance program please provide the information requested in the Other Health Coverage Section. Example Spouse covered by another insurance company or other Horizon Blue Cross Blue Shield of New Jersey coverage.

Aflac specified health event c... SPECIFIED HEALTH EVENT CLAIM FORM Accident Policy Number Hospital Indemnity/Specified Health Event Be sure to include your policy number s on all documents. Failure to complete this form in its entirety may result in a delay in processing this claim. INSTRUCTIONS Complete Section A Policyholder/Patient Information and sign your claim form. Have the treating physician complete Section B Physician s Statement and sign the claim form. If you are fil...

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