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Commercial operator insurance... Commercial Pesticide Operator Insurance Self- ?Certification Form Commercial Operator business name Business address License number (required unless it s a new license) Phone Email Insurance Company

Combined instructions and form... Financial Services Commission of Ontario Instructions for Form 5.2 Application to withdraw or transfer up to 50% of the Money Transferred into a Schedule 1.1 LIF General Information Use this application

San mateo care advantage visio... Page 1 of 2 PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM HEALTH PLAN OF SAN MATEO Plan/Medical Group Name: 650 Plan/Medical Group Phone#: ( ) 616-2088 650 Plan/Medical Group Fax#: ( ) 829-2045

Tricare other health insurance... Express Scripts P.O. Box 60903 Phoenix, AZ 850820903 Urgent: TRICARE needs information about your other health insurance (OHI) Dear TRICARE Beneficiary: Recently, Express Scripts learned that you

Maryland 15 dllr form State of Maryland Department of Labor Licensing and Regulation Division of Unemployment Insurance Telephones Baltimore Metropolitan Area 410 767-2412 Toll Free within Maryland 1-800-492-5524 Internet Address www. dllr. state. md. us DLLR/DUI 15 Rev. 12/12 181818 Round your entries to the nearest whole dollar. Omit dashes in social security numbers and commas and decimal points in wage amounts. Dllr. state. md. us DLLR/DUI 15 Rev. 12/12 181818 Round your entries to the nearest whole dollar. Omit dashes in social security numbers and commas and decimal points in wage amounts. Example Round 4 643. 27 to 4643 Valid reasons for not entering wages on this page follow 1. No wages were paid to employees this quarter and you choose to file this paper report instead of filing your no wage report by telephone or 2. You choose to file this paper report and your wages are reported on magnetic media. Note If you paid wages to employees and your wages are not filed via the internet telephone or on magnetic media this form and agency supplied continuation sheets must be used for reporting wages. 171717 Maryland Unemployment Insurance Quarterly Contribution Report 123456789 Do Not Staple Anything To This Form If typed disregard vertical bars type a consecutive string of characters. Exclude decimal point on lines 10 11 and 12. Include decimal point on lines 14 15 16 18 and 19. If hand printed print your characters in CAPS and within boxes as shown below. A B C D E F G H I J K L MN O P Q R S T U V W X Y Z DO NOT enter commas or signs. E-MAIL ADDRESS 1 If your e-mail address name and/or mailing address need s correction enter changes below and darken the box X 2 EMPLOYER NUMBER 3 FOR QTR ENDING MMD D Y Y D. B. A. NAME 7 If you changed the name of your business above darken the appropriate box. 8 Your telephone number on record is EMPLOYER S TELEPHONE NO. Name changed under same ownership IF YOU ENTER A DATE YOUR ACCOUNT WILL BE CLOSED. 11 Excess wages paid during the quarter to each employee in excess of 8 500 since January 1 See Instructions 12 Taxable wages subtract Line 11 from 10 FOLD HERE 14 Contributions for this quarter Multiply Line 12 by Line 13 15 Add interest if this report is filed after Due Date 16 Add 35. 00 Penalty if this report is filed after Due Date 17 Add Prior Balance Due as of 18 Less Approved Credit Memo. See Instructions 19 NET PAYMENT DUE Sum of Lines 14 15 16 and 17 minus Line 18. Payments may be made by check credit card ACH debit or ACH credit transaction* Make check payable to Payment plans are available. See Instructions Darken box if your business closed because it was acquired by another employer. For Office Use Only CR CB NO 16 DO NOT INCLUDE CENTS 13 Your Tax Rate for this quarter When completing lines 14 through 19 include cents and decimal points. Omit commas and signs. If your entry on a line is zero leave the line blank. If your telephone number shown is incorrect enter your correct area code number here. 9 If you do not expect to pay wages to employees after this quarter enter last date wages were paid* Note DO NOT enter date here if corporate officers continue to receive salary for services performed* entries to the nearest whole dollar.

Certificate of motor insurance... CERTIFICATE OF MOTOR INSURANCE (FORM B) CERTIFICATE NUMBER: MDFLT000416 1. Name of the Policyholder: ELTEL UK LTD 2. Effective Date of the commencement of the insurance for the purposes of the relevant

Nn0760e 2018 2019 form Claimants Statement For life insurance or investment For Affinity Market claims claims, send to: send to: Manulife Manulife 500 King Street North PO BOX 1602 WATERLOO ON N2J 4C6PO BOX 11023 STN CENTREVILLE MONTREAL

State farm life insurance form... Reset Form State Farm Mutual Funds Individual Retirement Accounts, Tax Sheltered Accounts (TSA) under 403(b)(7), or Archer Medical Savings Accounts (MSA). This form is used to designate or change

National western life insuranc... ANNUITY PARTIAL SURRENDER REQUEST (Please complete all noted areas. See page 2 for further instructions and information) POLICY NUMBER INSURED (MUST CHECK ONLY ONE) Amount Requested $ OR OWNER (If

Pearl carroll disability insur... Policy No. Claim No. I declare that the answers on Page 1 Page 2 and Page 3 of this form are complete and true to the best of my knowledge and belief. I also agree that I will advise the New York Life Insurance Company of my return to any type of work and that I will return any payments to which I am not entitled by reason of my return to work or termination of my disability. PLEASE NOTE ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION MO DAY YEAR Member s Signature The Member or someone on his/her behalf must sign here and on the Authorization for Release of Information Form. Please see that the completed form is returned to Fax 518-640-8105 Release From TO All providers of medical services and supplies pharmacy related service organizations prescription history database suppliers employers insurance institutions the Social Security Administration and other organizations. I authorize release to New York Life Insurance Company or their representative Pearl Carroll Associates LLC any independent claim administrators consulting health professionals pharmacy related service organizations and utilization review organizations with whom New York Life has contracted information concerning health care advice treatment or supplies provided the patient including that related to mental illness and/or AIDS/ARC/HIV and prescription records. STATEMENT OF RECOVERY OR RETURN TO WORK DISABILITY INCOME CLAIM INSTRUCTIONS PLEASE DETACH THIS NOTICE BEFORE MAILING AND KEEP FOR FUTURE REFERENCE Please answer all questions on the Member Statement on your Disability Income claim form and complete the List of Providers who have treated you. Date and sign both the Members Statement the Authorization for Release of Information and have your Medical Provider complete the rest of the form* Please see that the completed form is returned to Pearl Carroll Associates LLC PO Box 1519 Latham NY 12110 If you recover or return to work please notify New York Life immediately by completing and mailing the statement below to the above address. If you have any questions concerning your request for Disability Income benefits you may call the Office of the Administrator at 1-800-697-2732. Our fax number is 518-640-8105. Name Residential Address Social Security No* -- I recovered Policy G-11628 I returned to work on // Mo. Day Year Other Date Signature Email Address CSEA DI ed 5/2012 CSEA MEMBER S DISABILITY INCOME FORM Member Name Female Date of Birth Male No* Street City or Town State Zip Code Telephone No* Home Employer Weight Employer s Name Normal Number of Hours Worked Per Week Employer s Street Address Street City or Town What is the nature of your disability Is disability work related Yes Is disability due to an Injury Yes No If yes please attach a copy of the Employee Accident Report signed by manager If Yes when // Mo.

Online marine insurance form MARINE CARGO Insurance Proposal Form Intermediary Code Insurance Policy Number INSURED INFORMATION Name of Insured : Nature of Insureds Business Activity : Address : City : VAT No. : Telephone : Postal

Liberty videocon car insurance... Liberty Videocon General Insurance Company Limited 10th Floor Tower A Peninsula Business Park Ganpatrao Kadam Marg Lower Parel Mumbai - 400 013 Phone 91 22 6700 1313 Fax 91 22 6700 1606 Email care libertyvideocon.com IRDA registration number 150 l CIN U66000MH2010PLC209656 PROPOSAL FORM PRIVATE CAR INSURANCE POLICY Note 1 Please complete the proposal form in BLOCK LETTERS and tick boxes whichever applicable 2 Attach additional sheets if space given is insufficient 3 The queries made/details stated below are the minimum requirements to be furnished by a proposer. The Company may seek any other information as desired for underwriting purpose. Intermediary Details Name of the intermediary Code Intermediary Contact Details Branch Sales Manager Details Name of Sales Manager Vertical Proposal Details Proposal for New Vehicle Rollover Endorsement Renewal Type of Cover Package Comprehensive Policy Package Act Theft Policy Package Act Theft and Fire Policy Act only Policy Package Fire Theft Policy Proposer s Details Name and address for Communication Insured / Business Name Mr Mrs Ms M/s. Dr Contact Person Name to be specified in case of corporate customer Address for Correspondence City State Area Pin Code Contact Number a Residence b Mobile E-mail Address Date of Birth d m m y M Gender Business / Occupation For individual customers only F Please mention Registration Address Details of Vehicle Registration Number Date of Registration d Registering Authority and Location Rated under Engine Number Year of Manufacture Make of Vehicle Petrol Body Type Yes No No* of vehicles attached with fleet Is the vehicle made in India Four Wheeler Other Please specify A. Where the vehicle is primarily parked during daytime Closed garage Open garage Gated compound Others if others please mention C. Type of Road where vehicle would normally ply Hilly Roads National State Highways City-Town Road District Road Others if others please mention D. Vehicle Driven As on date Kms. Monthly average Insured s Declared value IDV Details IDV of the Vehicle Zone B Type of Vehicle Cubic Capacity Vehicle Colour Diesel Zone A Electrical accessories Non Electrical accessories Trailer Private cars Value of CNG/LPG kit Total IDV Insurance is the Subject matter of Solicitation* Fuel Type Chassis Number Seating Capacity Including Driver LVG-MO-P13-23-V01-12-13 Downloaded from www. insureatclick. com-Broker Loyal Insurance Brokers Ltd. Fax Number Details of Electrical Accessories Item Details Make Model IDV V1 - 2014 Call Toll Free No 1800 266 5844 www. libertyvideocon*com Details of Non Electrical Accessories CNG/LPG kit Is the Vehicle is driven by Non- Conventional Source of Power If yes please give details. Whether CNG/LPG kit fitted externally Whether the CNG/LPG Kit is manufacturer fitted Is the vehicle used for Commercial purposes If so whether the same is endorsed as such by RTA Whether the vehicle is certified as Vintage Car by Vintage Classic Car Club of India If so is the duty element is included in the IDV Whether the extension of Rally cover required Do you wish the Geographical Area Extension under your proposed Insurance cover If yes please select the relevant box Bangladesh Bhutan Nepal Sri Lanka Maldives Pakistan Personal Accident Cover for Owner Driver is compulsory in the Liability Only Cover.

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