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Form preview 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,
Form preview 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.
Form preview 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
Form preview 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.
Form preview Filing claims with the public... Filing a ?Hometown Heroes? Claim Public Safety Officers? Benefits Office Bureau of Justice Assistance A CHECKLIST FOR LAW ENFORCEMENT The Public Safety Officers? Benefits (PSOB) Act provides a one-time
Form preview Claim submittal form CLAIM SUBMITTAL FORM. Instructions: Please fill in the fields below, attach necessary documents if available, and submit your claim via one of the following ...
Form preview 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.
Form preview How to claim farm wineries and... Application for Farm Wineries and Vineyards Tax Credit VIRGINIA Form FWV Tax Year Submit this form by April 1. This credit must be approved before being claimed on your return. See instructions for details. Name FEIN/SSN Trading As/Business Name Contact Name Street Address Office Use Only City State ZIP Code Phone Number FAX Number Email Address Entity Type Check One Sole Proprietor C Corporation Partnership LLC Other The above named business qualifies as a Virginia farm winery - Virginia farm winery is defined as an establishment located in the Commonwealth that is licensed as a Virginia farm winery pursuant to Va. Code 4. Application for Farm Wineries and Vineyards Tax Credit VIRGINIA Form FWV Tax Year Submit this form by April 1. This credit must be approved before being claimed on your return* See instructions for details. Name FEIN/SSN Trading As/Business Name Contact Name Street Address Office Use Only City State ZIP Code Phone Number FAX Number Email Address Entity Type Check One Sole Proprietor C Corporation Partnership LLC Other The above named business qualifies as a Virginia farm winery - Virginia farm winery is defined as an establishment located in the Commonwealth that is licensed as a Virginia farm winery pursuant to Va* Code 4. 1-207. Virginia vineyard - Virginia vineyard is defined as agricultural lands located in the Commonwealth consisting of at least one contiguous acre dedicated to the growing of grapes that are used or are intended to be used in the production of wine by a Virginia farm winery as well as any plants or other improvements thereon* 1. Enter the total amount of qualified capital expenditures. Attach Schedule A to Form FWV giving the description and amount of each qualified expenditure date of purchase and supplier. Round to the nearest whole dollar. Be sure to retain the receipts for your records. Please note All expenses must be depreciated or claimed as an IRC 179 deduction* 2. Total credit requested* Multiply Line 1 by 25. 25. Round to nearest whole dollar. Declaration I we the undersigned declare under the penalties provided by law that this form including any accompanying schedules statements and attachments has been examined by me us and is to the best of my our knowledge and belief a true correct and complete application made in good faith pursuant to the income tax laws of the Commonwealth of Virginia* Authorized Signature Title Printed Name Date File Form FWV no later than April 1 for expenditures made during the preceding taxable year. Rev 08/13 3101030 Schedule A Farm Wineries and Vineyards Tax Credit Schedule Name as it Appears on Form FWV FEIN or Social Security Number Complete the below schedule if claiming the Farm Wineries and Vineyards Tax Credit. Copies of Schedule A can be submitted if additional space is needed* Date of Expenditure Detailed Description of Expenditure Amount of Supplier General Information An individual and corporate income tax credit is available for Virginia farm wineries and vineyards in an amount equal to 25 of the cost of all qualified capital expenditures made in connection with the establishment of new Virginia made to existing Virginia farm wineries and vineyards.
Form preview 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.
Form preview 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
Form preview 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
Form preview 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.
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