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Medical mutual of ohio claim f... DO NOT WRITE IN THE SPACE BELOW FOR MEDICAL MUTUAL USE ONLY 1. MEDICARE (Medicare #) NOT REQUIRED BY MEDICAL MUTUAL (Medicaid #) (Sponsor's SSN) (ID) 3. PATIENT'S BIRTH DATE SEX MM DD YY M F MEDICAID

Delta baggage claim form Property Loss Claim Form 5-1078 Rev 12. 09 You will likely receive your luggage within 24 hours. In the unlikely event you do not please contact the airport at which you filed the claim. If after 5 days you still have not received your luggage please fill out this form and submit it and all supporting documentation to Delta Air Lines. Inc. Customer Care Baggage P. O. Box 20598 Atlanta GA 30320-2598 Fax Number 888 880-3412 PLEASE DO NOT FILL OUT AND MAIL FORM UNTIL AFTER 5 DAYS HAVE ELAPSED WITHOUT YOUR LUGGAGE. We are sorry your luggage was not available after your recent flight. Store City Purchased ACME/Chicago Original Cost Other Currency USD Type Amount 3/1/1995 Total Value of Bag Contents ADDITIONAL COMMENTS List name of other persons or companies which may be on documents papers etc. Also any initials which may appear on personalized toiletry kits monogrammed shirts etc. Have you or a member of your family or household ever had a previous baggage property loss or claim with Delta Air Lines or any other airline Yes If yes please provide airline s name s and date s. 00 U.S. or more. Mailing Date PLEASE TYPE OR PRINT AND MAIL IMMEDIATELY Name Mr Mrs Miss/Ms Home Phone Area Code Home Address Employed By Business Phone City State Business Address City State Zip Country Zip /Postal Code Country Your Email Address Claim Check Number s Are You a SkyMiles Member Yes No Baggage File Reference number ex. ABCDL12345 SkyMiles Status SkyMiles YOUR COMPLETE ITINERARY To From Airline Flight Number Date Number of pieces checked Number missing Estimated weight of each missing piece Where did you check your luggage Curbside Airport Counter Departure Gate Other Was the bag checked under another name Yes No If yes what name Where did you last see your luggage Was Delta notified of loss immediately Yes No If yes which office Date Time In Person By Telephone Was loss reported to any other airlines Yes No If yes which airline If loss not reported immediately explain reason for delay Did you see your luggage in customs Yes No If no did you file a claim then Yes No With Whom Was excess valuation purchased at time of check-in Yes No If yes include copy of receipt. Should we be unable to locate your property please allow 6-8 weeks from mailing date for processing. Delta is not liable for loss of money jewelry computer/computer equipment cameras VCR s electronic/video or photographic equipment negotiable papers or securities heirlooms antiques artifacts works of art silverware irreplaceable books or publications/manuscripts/business documents precious metals and other similar valuables or commercial effects. Please note that itineraries traveled internationally are governed by the Montreal Convention and are not subject to the domestic tariff. RETAIN A COPY OF ALL DOCUMENTS e.g. CLAIM FORM AND RECEIPTS. The United States Post Office Department has investigative jurisdiction under federal laws relating to sending false or fraudulent claims through United States mails any such claims received by Delta Air Lines are reported to the United States postal authorities. Loss of luggage involving interstate shipment or articles from such luggage due to theft come within the purview of federal statues and therefore are subject to investigation by the Federal Bureau of Investigation. I do hereby warrant this statement and those on the accompanying form s to be accurate complete and true and I hereby make a claim against Delta Air Lines in the amount of for the loss occurring on 20 Claimant Signature Date Witness Signature Date Please be assured that if your property is located you will be contacted promptly. It is expressly understood and agreed that the furnishing of this proof of loss form by Delta Air Lines Inc. or assistance in making of the proof of loss is not a waiver of any rights or admission of liability by said Company and any other information and other documents required by said Company shall be furnished on request and considered a part of these proofs. The acceptance of this document shall not be deemed to be a waiver of any defenses of the Company. The Claimant expressly understands and agrees that he/she is required to immediately inform Delta Air Lines in writing in the event all or part of the property which is subject matter of this claim is delivered to Claimant from a source other than Delta its agents or employees. Loss of luggage involving interstate shipment or articles from such luggage due to theft come within the purview of federal statues and therefore are subject to investigation by the Federal Bureau of Investigation. I do hereby warrant this statement and those on the accompanying form s to be accurate complete and true and I hereby make a claim against Delta Air Lines in the amount of for the loss occurring on 20 Claimant Signature Date Witness Signature Date Please be assured that if your property is located you will be contacted promptly. Should we be unable to locate your property please allow 6-8 weeks from mailing date for processing. Delta is not liable for loss of money jewelry computer/computer equipment cameras VCR s electronic/video or photographic equipment negotiable papers or securities heirlooms antiques artifacts works of art silverware irreplaceable books or publications/manuscripts/business documents precious metals and other similar valuables or commercial effects. ABCDL12345 SkyMiles Status SkyMiles YOUR COMPLETE ITINERARY To From Airline Flight Number Date Number of pieces checked Number missing Estimated weight of each missing piece Where did you check your luggage Curbside Airport Counter Departure Gate Other Was the bag checked under another name Yes No If yes what name Where did you last see your luggage Was Delta notified of loss immediately Yes No If yes which office Date Time In Person By Telephone Was loss reported to any other airlines Yes No If yes which airline If loss not reported immediately explain reason for delay Did you see your luggage in customs Yes No If no did you file a claim then Yes No With Whom Was excess valuation purchased at time of check-in Yes No If yes include copy of receipt. Were you charged for extra pieces/excess weight at time of check-in Yes No If yes include copy of receipt. DESCRIPTION OF LUGGAGE Type Brand Color Material Pockets Zipper Wheels Straps Combo Lock Purchase Original Yes No Yes No Yes No Yes No Yes No Cost Continued On Next Page FORM NO.

Harrison flex plan form Flexible Benefits Plan Claim Form OFFICE USE ONLY Claim Number http //harrisonflex. aibpa.com Employee Information Last Name Print First Name Street Address City Check if new address Social Security Number MI State Phone Number Submit Claims To Harrison Flex Plan 1220 SW Morrison Street Suite 300 Portland OR 97205 Fax 503 228-0149 Zip Date of Birth INSTRUCTIONS Please provide claim patient information. Is the patient Self Spouse Child Other. If other specify NOTE No patient information required when submitting Explanation of Benefits from insurance company. Sex Disabled Full Time Student mo/day/year Patient Information Last Name M F Yes No requirements and for information on how to apply for each specific benefit. Type of Claim Supplemental Workers Compensation Unemployment Benefit Dislocation You must provide proof payment. Date s and Number of weeks requested Local 48 will verify eligibility. First half of account Second half of account Taxable You are relocating to Local Address Local Number of weeks requested Medical Care Reimbursement Plan Premium Pay Plan For Harrison Health Plan Coverage ONLY Dependent Care You must submit an Explanation of Benefits showing date and type of service or Medical Care Expense Receipts. Amount requested Filing Jointly Filing Single Partial Payment/Full Payment for Continued Health Coverage Please submit Dependent Care of service and name address and TAX ID number of person s performing the service. Dates From Thru No check generated Signature of Participant For expenses incurred on or after January 1 2011 you will be required to provide a physician s prescription with your Ove r-the-Counter reimbursement claim request s per IRS requirements. Please go to www*irs*gov refer to publication 502 for more detailed information* For Wage Replacement Claims Please submit a W-4 form along with your claim* If you do not submit a W -4 form taxes will be taken out based on taxes for a married person filing jointly. Forms are available at http //harrisonflex. aibpa*com or http //www*irs*gov* I certify that I have read the instructions and that the above information is complete and accurate. I also certify that all claims submitted will be only for me or for my dependents that are eligible for benefits under the plan* Additionally I certify that there is no other coverage for my dependents or me provided by another insurance company or employer for the benefit that I am seeking coverage. I understand that I will be responsible to reimburse the Trust Fund for all amounts paid in connection with claims for me or my dependents if I make any false statements or misrepresentation in this form or in any claim form or if I conceal any information pertaining to any such claims. I agree to provide the Trust Fund upon request with verification of any information* I give permission to A I Benefit Plan Administrators to examine records pertaining to myself or covered dependents as required to process claims. Signature of Employee FOR MORE INFORMATION ABOUT THESE BENEFIT REQUIREMENTS SEE YOUR BENEFITS BOOKLET White-Trust Office Yellow-E*O.

Pge form 62 1444 CLAIM FORM Mail To PG E Law - Claims Dept. 1850 Gateway Blvd. 6th Floor Concord CA 94520-OREmail to LawClaims pge. com -ORFax to 925-459-7326 Helpline phone 415-973-4548 PLEASE PRINT 62-1444 Rev 2/2011 Mr. / Mrs. / Ms.

Schedule of florida sales or u... Paid on Orig. Pur. ... Use Form DR-95B to calculate credits for sales and use tax paid on ... Column 4 - Sales tax paid on original purchase - include discretionary ...

This evidence of insurance doc... INTERNATIONAL PAPER INSURANCE DOCUMENTATIONFor Year 2020This evidence of insurance documentation is provided for our business partners, including customers and property/equipment lessors, who require

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Travel insurance documents for... TRAVEL INSURANCE CLAIM FORM AAR INSURANCE KENYA LIMITED GEORGE WILLIAMSON HOUSE, 4TH GONG, 2ND FLOOR, P.O. BOX 4176600100, TEL: 020 2895000/2715319 FAX: 020 2715328, EMAIL: info AAR.co.KE MESA PLAYBILL

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