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Spousal amp dependent insuranc... NECA-IBEW WELFARE TRUST FUND SPOUSAL & DEPENDENT INSURANCE FORM Date YOUR EMPLOYEE Social Security # OUR Member Social Security/ID# Please have the employer complete the following information and

Exemption application for insu... Form Approved OMB No. 0938-1190 Application for Exemption from the Shared Responsibility Payment for Individuals who are Unable to Afford Coverage and are in a State with a Federally Facilitated Marketplace

Insurance form ? Life? Insurance? Quote? Request? Form? ? Proposed? Insured? ? ? ? ? Name?(First, ?MI, Last)?? ? ??? Male? ? Name?(First, ?MI, Last)? ?? ? ? ?????? Male? ???????????? Female? ? ? ? ? ?????? Female?

Verification of income and hea... Verification of Income and Health Insurance Complete one form for each job for every adult in the household. Complete the top portion and give the form to your employer. Attach copies of the pay stubs

Erika insurance form Claim form EF program name High School Exchange Year Language Courses Abroad Academic Programs personal information First Name EF Academy Language Travel EF Corporate Solutions Other: Address in home

Nepal life insurance form American General Life Insurance Company P O Box 305355 Nashville, TN 37230-5355 POLICY LOAN APPLICATION COMPANY CODE # POLICY NUMBER NAME OF INSURED OWNER'S ADDRESS-STREET AND NUMBER I. TELEPHONE

Iso insurance forms pdf 2. 124 of the Code of Virginia. This form includes copyrighted material of Insurance Services Offices Inc. with its permission and may only be used by a licensed insurer in Virginia for risks located in Virginia. Use of this form for any other purpose shall be with the express permission of ISO and subject to the standard ISO copyright notice. ISO Properties Inc. 2005 Page 1 of 11 TRUCKERS DECLARATIONS COMPANY NAME AREA PRODUCER NAME AREA ITEM ONE Mailing Address Policy Period From To Previous Policy Number Form Of Business Partnership Named Insured At 12 01 A. M. Standard Time at your mailing address Limited Liability Company Other Individual In return for the payment of the premium and subject to all the terms of this policy we agree with you to provide the insurance as stated in this policy. COMMERCIAL AUTO CA DS 14 03 06 O N LY POLICY NUMBER Insurance Services Office Inc* Copyright SP EC IM EN This form has been promulgated by the Virginia State Corporation Commission for use by all licensed insurers in the Commonwealth issuing policies for motor vehicle insurance as defined in 38. ISO Properties Inc* 2005 Page 1 of 11 TRUCKERS DECLARATIONS COMPANY NAME AREA PRODUCER NAME AREA ITEM ONE Mailing Address Policy Period From To Previous Policy Number Form Of Business Partnership Named Insured At 12 01 A. M. Standard Time at your mailing address Limited Liability Company Other Individual In return for the payment of the premium and subject to all the terms of this policy we agree with you to provide the insurance as stated in this policy. Premium shown is payable at inception Annually Semi-Annually Quarterly Monthly Audit Period If Applicable Endorsements Attached To This Policy IL 00 17 Common Policy Conditions IL 01 46 in Washington IL 00 21 Broad Form Nuclear Exclusion Not Applicable in New York Countersignature Of Authorized Representative Name Title Signature Date Note Officers facsimile signatures may be inserted here on the policy cover or elsewhere at the company s option* Limit Covered Autos Coverages ITEM TWO Schedule Of Coverages And Covered Autos This policy provides only those coverages where a charge is shown in the premium column below. Each of these coverages will apply only to those autos shown as covered autos. Autos are shown as covered autos for a particular coverage by the entry of one or more of the symbols from the Covered Autos Section of the Truckers Coverage Form next to the name of the coverage. Premium Personal Injury Protection Or Equivalent No-Fault Added Personal Injury Equivalent Added No-Fault Coverage Property Protection Insurance Michigan Only Medical Payments Uninsured Motorists Underinsured Motorists When Not Included In Separately Stated In Each Personal Injury Protection Endorsement Minus Deductible. Liability For Each Accident. Trailer Interchange Comprehensive Actual Cash Value Cost Of Repair Or Whichever Is Less* Minus Deductible For Each Covered Auto For Loss Caused By Mischief Or Vandalism* Auto. Auto But No Deductible Applies To Loss Caused By Fire Or Lightning. Physical Damage Each Covered Auto For Loss Caused By Mischief Or Collision Coverage Towing And Labor Specified Causes Of Loss Coverage For Each Disablement Of A Private Passenger Auto.

Reliance insurance form A Reliance Capital Company 1800 3002 8282 (toll-free) 3989 8282 (local charges apply) www.reliancegeneral.co.in Reliance Travel Care Policy Extension Request Form (Request for Single Insured Only)

Hmms certificate of insurance... 2. If a facsimile has been transmitted the original certificate must follow. 3. Insurance company must be licensed to operate in Canada. Name of Insured Telephone Number including area code Fax Number including area code Insured s Address Apartment/Suite Number Street Number Street Name City Province Postal Code Type of Insurance Insurance Company Policy Number Full Legal Name Effective Date Year/Month/Day Expiry Date Commercial General Liability...

State life insurance form down... FORM G STATE LIFE INSURANCE CORPORATION OF PAKISTAN State Life Building 15A Sir Aft Khan Road, (Davis Road) Lahore. GROUP & PENSIONS DIVISION For Office Use OnlyCertificate No. Date: Registration

Rspcapetinsurance form Need more Claim Forms You can access copies of this form online at rspcapetinsurance. org. au or by calling 1300 855 150 between 8 00am 8 00pm Monday to Friday EST. Veterinary Fee Claim Form Claims should be submitted in writing and received with the original itemised invoice s within 90 days of the vet treatment being provided* Faxed claims will not be accepted* 1. To be completed by you the Policy owner Policy number Your pet s details Your pet s name Species Male Gender Female Desexed Pet s age/ date of birth Yes Dog Cat No Colour Breed Title First name Surname Address Suburb State Phone work home Postcode mobile Email Please tick 3if there has been a change of address or contact details If you are registered for GST and are entitled to a GST Input Tax Credit ITC on your premium what is the ITC percentage ABN By leaving these details blank the insured confirms that no entitlement to GST ITC exists. Type and cause of injury or condition/diagnosis being claimed Date of treatment Dates of first clinical signs include dates of previous related or similar conditions Total charge Case summary Please attach full veterinary history radiology pathology reports and consultation notes where applicable. How long has this pet been a client of your clinic Less than 6 months More than 6 months Notes Note If this is your pet s first claim please attach a complete veterinary history medical records from both current and previous veterinary clinics. If you have previously provided this information to us or if it is a routine care claim you do not need to provide it. Type of vaccination Date of last vaccination/booster 3. Declaration SIGN HERE I/we certify that the information given in this form is truthful accurate and complete. No information likely to affect this claim has been withheld. I/we understand that deliberate misrepresentation of the animal s condition or the omission of any material facts may result in the denial of the claim and/or cancellation of the policy. I/we confirm that the veterinary services as detailed in the account s submitted with this claim have been provided and I/we understand that policy administrators will assess the claim in accordance with the cover selected and benefits payable by the policy. I/we authorise any veterinary surgeon who has treated my/our pet to provide to the insurer any details they may require. Please note that issuance or completion of this form does not acknowledge liability or guarantee payment of the claim* Signature of Policy owner Signature of Veterinarian Your Veterinarian Registration Number DD / MM / Y Y Y Y Name of attending veterinarian and practice please print or stamp Date Registration State Please mail your completed claim form to RSPCA Pet Insurance Locked Bag 9021 Castle Hill NSW 1765 PLEASE DO NOT STAPLE DOCUMENTS Make a claim in three easy steps Step one Fill in your and your pet s personal information and sign the Claim Form* Step two Take the form to your vet and ask your vet to fully complete section 2 and sign the form* Step three Attach the original detailed itemised invoices and payment receipts to the completed RSPCA Pet Insurance Claim Form* Please do not staple documents.

Unity health insurance form Name of Insurance Co. I would have to pay more than 10 percent of my annualized gross income towards health insurance Other reason for waiving I certify that I have been given the opportunity to apply for the Unity group health benefit plan coverage for which I am eligible. Original. A legible facsimile or electronic signature shall have the same force as the original. obtain medical records from health care providers who have treated me my spouse or any dependents applying for coverage under this application. If medical records are needed Unity will provide me with an authorization form. NOTICE OF SPECIAL ENROLLMENT RIGHTS If you are declining enrollment for yourself or your dependents including your spouse because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage or if the employer stops contributing towards your or your dependents other coverage. State Zip Code County City Mailing Address if different Single Divorced Date of Birth Gender Marital Status M F Married Primary Language Spoken English Spanish Other provide date when marriage occurred Home Phone Cell Phone Primary Care Physician PCP and Clinic Work Phone Applicant s E-Mail Address If you want Unity to assign you to a Clinic or a PCP indicate ASSIGN Current Patient Yes No UH00674 rev 09 16 DEPENDENT INFORMATION Please list all other members to be covered Dependent s Last Name Relationship OTHER INSURANCE INFORMATION Will you or any of your dependents continue to have other insurance after the Unity Health Insurance effective date of this policy If Yes complete Subscriber Effective Date of Coverage Group Termination Date Are you or your spouse or child ren covered by Medicare Parts A B C or D If yes please list name s Reason for Medicare Age 65 Part A Effective Date Disability End Stage Renal Disease Disability and ESRD Are you or any dependents listed above involved in a Workers Compensation case If Yes indicate who is involved and start date / accident date Workers Compensation Condition WAIVER of GROUP COVERAGE I hereby elect not to apply for group health plan coverage. Employee Application Please Complete Entire Form in BLACK INK. 840 Carolina Street Sauk City WI 53583-1374 800 362-3309 Fax 608 643-2564 unityhealth. com FOR EMPLOYER USE EMPLOYMENT INFORMATION Name of Employer Group Employment Status Plan Requested Hours Worked Per Week // Active Retired LOA COBRA / Continuation Effective Date // and Term Date // HMO POS PPO Group Number Type of Coverage Date Employed Employee Employee and Spouse Employee and Child ren Family Requested Effective Date of Coverage // Reason for Enrollment check appropriate box New Hire Loss of other coverage Name change / address change / PCP change Return from layoff date // Transfer to disability segment Marriage Open enrollment Part-time to full-time employment Birth adoption / placement for adoption Add / delete dependents Rehire date // Transfer to retiree segment Other date of change // Late applicant COBRA / State Continuation election For loss of other coverage please complete Insurance Company Phone Subscriber Effective Date of Coverage Termination Date Names of those covered under policy EMPLOYEE INFORMATION Please do not use abbreviations or nicknames on this application Employee s Last Name First Name MI Social Security Number or Tax ID Number SSN / TIN is required for IRS tax reporting regarding your health plan* Street Address Apt.

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