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Workers compensation disputed... Mail To: LOCAL DISTRICT OFFICE OR 1. 2. 3. 4. 5. 6. Docket Number Social Security No. Date of Injury/Illness Part(s) of Body Injured Date of This Request Date of Hire Date of Birth - - - OFFICE OF

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

Insurance documentation form INTERNATIONAL PAPER INSURANCE DOCUMENTATIONFor Year 2018This evidence of insurance documentation is provided for our business partners, including customers and property/equipment lessors, who require

International paper insurance... INTERNATIONAL PAPER INSURANCE DOCUMENTATIONFor Year 2017This 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

Your insurance documentation b... Your Insurance Documentation British Airways American Express Credit Card YOUR INSURANCE DOCUMENTATION BRITISH AIRWAYS AMERICAN EXPRESS CREDIT CARD Contains: Key Information: (i) Policy Summary (ii)

Life insurance application lz... LIA-WP (10/08) LIFE INSURANCE APPLICATION 100 Quentin Roosevelt Boulevard, Garden City, NY 11530 Internet address: www.wpenn.com INSTRUCTIONS As the Agent, you are responsible for completing the necessary

Utah health insurance applicat... Page 1 of 5 Utah Small Employer Health Insurance Application July 2009 D. WAIVER OF COVERAGE Complete this section for yourself if waiving and/or any of your dependents for whom you are waiving coverage. UTAH SMALL EMPLOYER HEALTH INSURANCE APPLICATION OFFICE USE ONLY Policy / Group No. REASON FOR ENROLLMENT mark all that apply New Group Newborn Loss of Coverage Open Enrollment Marriage Court Order New Hire Divorce Other New Application Re-apply Dependent Addition Date of Event COBRA / Utah mini-COBRA / Alternative Coverage for Employee Dependent Employer Name Effective Date PEC New Hire Waiting Period Length of COBRA continuation coverage 18 mos. 36 mos. Other Original Qualifying Event Date Qualifying Event Date Coverage Medical Dental Vision Self COVERAGE REQUESTED Spouse Child ren COBRA Utah mini-COBRA Alternative Coverage A. EMPLOYER INFORMATION Employer Hire Date Location Is this a division Yes Rehire Date No If Yes name of parent company Name Last Marital Status First Legally Married Single MI Widowed Home or other Phone Hrs/Week Domestic Partner Apt. Address Job Title City State Business Phone Spouse s Business or other Phone Spouse s Employer Zip Driver s License Number Email Address C. ENROLLING EMPLOYEE / SPOUSE / DEPENDENTS attach separate sheet if necessary In the section below list yourself and all eligible family members to be included under coverage. Social Security for internal use only Name Last First MI Date of Birth No lbs. Dependent Rx M/F Age Weight HICN Eligible family members include spouse natural child stepchild adopted child child placed for adoption and child for whom you are appointed as legal guardian by the court. To be eligible for coverage children must be under the age of 26 unmarried and dependent upon you for 50 percent of their financial support. Financial dependency is not required for courtordered child coverage. Any dependent not listed will not be considered for coverage. You may not enroll dependents if you are waiving except children subject to a Qualified Medical Child Support Order. If you decline enrollment in this plan for yourself and/or any of your dependents including your spouse because of other health care coverage you may in the future be able to enroll the omitted individual s in this plan provided that you request enrollment within 30 days after the other coverage of the individual s ends. Decline enrollment includes omission of the individual from this application* In addition if you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents provided that you request enrollment within 30 days after the marriage birth adoption or placement for adoption the Special Enrollment Period. Please complete type of health care coverage for the employee and all eligible members who have other health care coverage by completing type of health care coverage i*e* group individual or other Medicare Medicaid V. A. H. I. P. etc*. All eligible family members must be listed in this section or the ENROLLING EMPLOYEE / SPOUSE / DEPENDENTS section* Persons waiving coverage.

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