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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.

Carefirst blue cross blue shie... INSTRUCTIONS TO SUBMIT A MAJOR MEDICAL CLAIM When you have enough charges to satisfy your deductible, you may file a Major Medical claim! You DO NOT have to wait until the end of the year. In fact,

Washington quitclaim form QUITCLAIM DEED SAMPLE THIS SPACE PROVIDED FOR RECORDER S USE FILED FOR RECORD AT REQUEST OF John Smith WHEN RECORDED RETURN TO NAME John Smith ADDRESS P. O. Box 320 CITY STATE ZIP Seattle WA 98101 THE GRANTOR S John Smith for and in consideration of One dollar and love and affection conveys and Quitclaims to the GRANTEE S John Smith Jr. and Mary Smith husband and wife the following described real estate situated in the County of King State of Washington together with all after acquired title of the Grantor s therein legal description The Southerly 90 feet of lots 8 and 9 Block 12 Stewart s first addition to Highland home an addition to the City of Seattle as per plat recorded in Volume 2 of plats page 85 Records of King County situated in the County of King State of Washington. Tax Parcel Number 3355479823 DATED Grantor State of Washington County of ss On this day personally appeared before me and Grantor s to me known to be the individual s described in and who executed the foregoing instrument and acknowledged that s/he signed the same as his/her free and voluntary act and deed for the uses and purposes therein mentioned. GIVEN under my hand and official seal this day of NOTARY PUBLIC in and for the State of Washington Residing at My commission expires NAME ADDRESS CITY STATE ZIP the following described real estate situated in the County of after acquired title of the Grantor s therein legal description described in and who executed the foregoing instrument and acknowledged that s/he signed the same as his/her free and voluntary act and deed for the uses and purposes therein mentioned. Residing at. Quitclaim Deeds and Life Estates What is a Quitclaim Deed What if I want my property back after I sign the form All real estate transactions must be in writing. If you change your mind later and decide you want to keep the property it may be impossible or very hard to undo the deed unless the Grantee agrees to Quitclaim the property back to you. A quitclaim deed is one way to transfer real property such as A house or Land or Certain mobile homes. If the Grantee refuses to Quitclaim the prove that the transfer was invalid* Examples You signed the deed under threats or other extreme pressure or you signed it due to lies the Grantee told you. You may have to hire a lawyer to invalidate the transfer. That can be very expensive. It may not work. The person who transfers the property by selling it or making a gift of it is called the Grantor. The person the property is transferred to is the Grantee. types of deeds. The Grantor of a Quitclaim deed makes no guarantee or promises that the property is free of debt. Also with a Quitclaim deed the Grantor makes no promises that no one else claims to own Do not sign the quitclaim deed if you feel threatened or RUSHED OR under pressure to sign it. Do not sign the deed if you feel the person you are giving the property to may be lying about something related to the property or your ability to continue living there.

Kansas form d 22a KANSAS DEPARTMENT OF REVENUE DIVISION OF VEHICLES DEALER LICENSING BUREAU DOCKING STATE OFFICE BUILDING TOPEKA, KANSAS 66626-0001 Phone: (785) 296-3621 Fax (785) 296-5854 Web Site: www.ksrevenue.org/dmv

Fedex claim form Fedex. com/claim.jsp. all customer service at 1. 866. 393. 4585. omplete a claim form and e-mail fax or mail it see step 3. FedEx Freight Form Instructions and Frequently Asked Questions FAQs Read the following FAQs for answers on the claim resolution process. Can I get updates on the status of my claim If you use our online filing option at Step 3 -mail fax or mail the completed claim form with the E supporting documentation to file. claim fedex. com Fax 1. 877. 229. 4766 FedEx Cargo Claims Dept. P. O. Box 256 Pittsburgh PA 15230 I f you fax your claim you will receive a confirmation letter by return fax. 31581PL 1/09 Claim Form For lost or damaged U.S. or international shipments Sender or Shipper s Name / Contact Recipient s or Consignee s Name / Contact Company Address City State / Province Country ZIP / Postal Code Phone Fax E-Mail Tracking or Freight Bill Numbers Shipment Information Loss Complete Partial Additional tracking numbers for this claim request allowed must have same sender recipient and ship date Ship date No. of packages Weight FedEx control number NOTE Call 1. All claims will be resolved based on the merits of the claims investigation. How long will the claim resolution process take Most cases will normally be resolved in 5 to 7 business days after we receive your claim form and supporting claim What should I do with the merchandise and shipment packaging Keep the merchandise and all original packaging including cartons and contents until the claim resolution process is finished. It may be necessary to make the packaging available to FedEx for inspection. Where can I find specific information about the claim resolution process For more detailed information refer to the National Motor Freight Classification series and the FXF Rules Tariff series for exclusions of liability and additional limitations. Who can file a claim The sender the recipient or a third party can file the claim* How do I file a claim Follow the three easy steps listed below to file your claim* Step 1 Choose one of the following options omplete and submit a claim form online at C fedexfreight. Step 2 Gather the following documentation hotocopy of FedEx air waybill FedEx Ship P Manager printout FedEx Ground Pick-Up Record or delivery receipt. ll documentation related to the proof of value copy A of original invoice from vendor or supplier copy of retail invoice or receipt final confirmation screen if online order with proof of payment itemized repair invoice or statement of non-repair appraisals expense statement or any other applicable documentation. Serial number s of merchandise if applicable. Inspection report if applicable. When should I file my claim Claims for concealed loss and visible or concealed damage must be reported within 21 calendar days and all supporting Claims for non-delivery must be filed within 9 months of the committed delivery date. Can I get updates on the status of my claim If you use our online filing option at Step 3 -mail fax or mail the completed claim form with the E supporting documentation to file.

Cigna healthcare form Clear Fields Form Information Member Claim Form Insured and/or Administered by Connecticut General Life Insurance Company Not to be used for Pharmacy or Dental claims CIGNA HealthCare This form can be used for all medical plans. 5. Use a separate claim form for each provider and each member of the family. A new form can be obtained from www. cigna.com under HealthCare Important Forms or by calling Member Services using the toll-free number on your CIGNA ID card. Cigna.com under HealthCare Important Forms or by calling Member Services using the toll-free number on your CIGNA ID card. 6. Your claim cannot be processed without your ID Number Employee Section Block D. Please reference the front of 7. Send your completed claim form and itemized bill s to the CIGNA address listed on your identification card. If you have additional questions please contact Member Services using the toll-free number on your ID card. EMPLOYEE S SIGNATURE DATE X PAYMENT INSTRUCTIONS I authorize payment to be made directly to the healthcare provider s indicated on the enclosed bill s Please be aware that if the provider of service holds a contract with CIGNA payment will always be made to the provider even if this section is not signed. If the provider is contracted with CIGNA the provider will be paid by CIGNA at the contracted rate. If you have already paid for services you should seek reimbursement directly from the provider. NOTE The information provided on this form may be disclosed to other persons or entities including my Plan Sponsor for the purpose of processing this claim and performing health plan administration. 591692a Rev. 10/2008 Return To Page 1 INSTRUCTIONS FOR FILING A CLAIM IMPORTANT claim on your behalf. Out-of-network claims can be submitted by the provider if the provider is able and willing to file on your behalf. 2. CERTIFICATION Any person who knowingly and with intent to defraud any insurance company or other person 1 files an application for insurance or statement of claim containing any materially false information or 2 conceals for the purpose of misleading information concerning any material fact thereto commits a fraudulent insurance act which is a crime. For residents in the following states please see the last page of this form Alaska Arizona California Colorado District of Columbia Florida Kentucky Maryland Minnesota New Jersey New York Oregon Pennsylvania Tennessee Texas and Virginia. I certify that the information supplied is true and correct. EMPLOYEE S SIGNATURE DATE X PAYMENT INSTRUCTIONS I authorize payment to be made directly to the healthcare provider s indicated on the enclosed bill s Please be aware that if the provider of service holds a contract with CIGNA payment will always be made to the provider even if this section is not signed. If the provider is contracted with CIGNA the provider will be paid by CIGNA at the contracted rate. This form only needs to be completed if the provider is not submitting the claim on your behalf* Out-of-network claims can be submitted by the provider if the provider is able and willing to file on your behalf* Please refer to reverse side for instructions.

Claim oakland form CLAIM AGAINST THE CITY OF OAKLAND Please return the completed form to the Office of the City Attorney One Frank H. Ogawa Plaza 6th Floor Oakland CA 94612. Additional sheets may be attached as necessary. Enclose a postage paid envelope if you require a filing receipt. 1 CLAIMANT S NAME 2 ADDRESS City State HOME DRIVER S LICENSE WORK SOCIAL SECURITY CELL DATE OF BIRTH OCCUPATION AUTO INSURANCE NAME AND POLICY if applicable Zip 3 IF AMOUNT CLAIMED IS LESS THAN 10 000 AMOUNT OF CLAIM Attach copies of expenses substantiating the basis of computation for the amount being claimed Yes No Unsure 4 ADDRESS TO WHICH NOTICES ARE TO BE SENT IF DIFFERENT FROM LINES 1 2 NAME PHONE 5 DATE OF INCIDENT TIME OF INCIDENT SPECIFIC LOCATION OF INCIDENT Address 6 DESCRIBE THE INCIDENT INCLUDING YOUR REASON FOR BELIEVING THE CITY IS LIABLE FOR YOUR DAMAGES 7 DESCRIBE ALL DAMAGES WHICH YOU BELIEVE YOU HAVE INCURRED AS A RESULT OF THE INCIDENT 8 NAME S OF PUBLIC EMPLOYEE S CAUSING THE DAMAGES YOU ARE CLAIMING 9 WERE PARAMEDICS CALLED 10 IF YOU WENT TO A DOCTOR LIST HIS NAME ADDRESS TELEPHONE NUMBER Date of 1st Visit X Signature of Claimant or Representative Is there a police report on file V A Date Complete the diagram on the back of this form showing the location of the incident Any person who with the intent to defraud presents any false or fraudulent claim may be punished by imprisonment or fine or both. Ogawa Plaza 6th Floor Oakland CA 94612. Additional sheets may be attached as necessary. Enclose a postage paid envelope if you require a filing receipt. 1 CLAIMANT S NAME 2 ADDRESS City State HOME DRIVER S LICENSE WORK SOCIAL SECURITY CELL DATE OF BIRTH OCCUPATION AUTO INSURANCE NAME AND POLICY if applicable Zip 3 IF AMOUNT CLAIMED IS LESS THAN 10 000 AMOUNT OF CLAIM Attach copies of expenses substantiating the basis of computation for the amount being claimed Yes No Unsure 4 ADDRESS TO WHICH NOTICES ARE TO BE SENT IF DIFFERENT FROM LINES 1 2 NAME PHONE 5 DATE OF INCIDENT TIME OF INCIDENT SPECIFIC LOCATION OF INCIDENT Address 6 DESCRIBE THE INCIDENT INCLUDING YOUR REASON FOR BELIEVING THE CITY IS LIABLE FOR YOUR DAMAGES 7 DESCRIBE ALL DAMAGES WHICH YOU BELIEVE YOU HAVE INCURRED AS A RESULT OF THE INCIDENT 8 NAME S OF PUBLIC EMPLOYEE S CAUSING THE DAMAGES YOU ARE CLAIMING 9 WERE PARAMEDICS CALLED 10 IF YOU WENT TO A DOCTOR LIST HIS NAME ADDRESS TELEPHONE NUMBER Date of 1st Visit X Signature of Claimant or Representative Is there a police report on file V A Date Complete the diagram on the back of this form showing the location of the incident Any person who with the intent to defraud presents any false or fraudulent claim may be punished by imprisonment or fine or both. PLEASE READ CAREFULLY If claim is for injury and you are still under doctor s care indicate that on the form and submit medical bills to date with status of your condition* If property damage is involved submit two estimates of repairs or paid invoices to substantiate amount claimed* If the accident involved a vehicle give the following information YEAR/MAKE OF THE VHEICLE LICENSE NO.

Delta dental claim form 3105 Delta Dental Insurance Company P.O. Box 1809 Alpharetta, GA 30023-1809 www.deltadentalins.com STAPLE X-RAYS FOR ALL MAJOR SERVICES TO TOP LEFT CORNER OF FORMS. X-RAYS MUST BE LABELED WITH PATIENT

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