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The federalist society for law... The Federalist Society for Law & Public Policy Studies 20152016 Student Chapter Reimbursement Request Form Requests must be submitted within 3 months of the event date. Chapter Copies of receipts

Pharmacy policy form 3 SCOPE This policy shall apply to all CARE Pharmacies pharmacy sites. This proprietary communication contains information that is confidential and may be privileged and exempt from disclosure under applicable law. Pharmacy Responsibilities Including Ethical Conduct The policy serves to establish guidelines with regard to ethical business conduct job designations specific assignments and expectations of pharmacy personnel and his or her provision of services. Community Pharmacy Quality Assurance Policy Manual NOTICE OF CONFIDENTIALITY This quality assurance policy and procedure manual is intended solely for the use of the CARE Pharmacies Inc if you are not the intended recipient you are hereby notified that any use disclosure dissemination or copying of this communication is strictly prohibited. Thank you for your cooperation. CARE Pharmacies Inc. 100 Daingerfield Road Suite 400 Alexandria VA 22314 SYNOPSIS Who is expected to do what and when and how The intent of the QA manual is to establish and maintain a cohesive approach to daily pharmacy operations. 2 RESPONSIBILITIES a The Pharmacy Manager or Pharmacist-in-Charge PIC will oversee policy compliance for personnel under his or her supervision. b All CARE Pharmacies employees and contractors will adhere to the policies and SOPs in this manual. c The Quality Assurance department reserves the right to regularly perform audits both on and off site. X Inspectors must agree to adhere to the pharmacy inspection policy as outlined as well as other pharmacy procedures as applicable during the inspection. b Internal Audits The internal auditor will assist in the management of overall quality and compliance activities by ensuring operational adherence to corporate policies industry standards and applicable regulations. Regard to the privacy policy. CARE Corporate as well as the department of Health and Human Services HHS are alternative points of contact with regard to the communication of any complaint concern or inquiry. ii Pharmacy management shall make a good faith effort to alleviate any potential harmful effects caused or incurred as a result of noncompliance to HIPAA guidelines. Further I have been advised and I understand the penalties to include disciplinary action or termination associated with failure to comply with or failure to report violations of said policy. Signature Printed Name Position Authorizing Signature Copy of training acknowledgement record is to be retained on file. PHARMACY PRIVACY and INFORMATION SECURITY PRACTICES OVERVIEW As a customer/patient of this CARE Pharmacy I understand the following 1. QA manual. Further pharmacy personnel shall be advised of disciplinary actions activities. of monetary value prison time or both depending on the nature of the offense. 2 Violators may be subject to disciplinary action to include written or verbal warnings suspension or termination for lack of compliance or conformance to this policy or for failing to report any witnessed or known violation of this policy.

Form 275 021 04 contractor cer... Form 27502104 Equal Opportunity Office 3/2004 CONTRACTOR CERTIFICATION OF EEO/AA POLICY AND PLAN ADOPTION Directions: Access www.myflorida.com/equalopportunityyoffice/ to review the policy and plan

Notice of proposed policy 1604... MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES NOTICE OF PROPOSED POLICY Public Act 280 of 1939, as amended, and consultation guidelines for Medicaid policy provide an opportunity to review proposed

Tsa 403b policy loan request f... JEFFERSON NATIONAL LIFE INSURANCE COMPANY P.O. Box 36840, Louisville, KY 40233 Fax: 1-866-667-0563 ? TSA (403(b)) POLICY LOAN REQUEST FORM CONTRACT # OWNER SSN# - - or EIN - ADDRESS E-MAIL DAYTIME

A medicare supplement insuranc... Spontaneous. Fun* Fearless. United of Omaha Life Insurance Company A Mutual of Omaha Company The Facts About Your Plan Your United of Omaha Medicare supplement insurance policy helps pay some eligible expenses not paid for by Medicare Part A and Medicare Part B. There may be charges above what Medicare and United of Omaha pay. Medicare Part A Eligible Expenses for Hospital/ Skilled Nursing Facility Care include expenses for semiprivate room and board general nursing and miscellaneous services and supplies. Services include expenses for physicians services hospital outpatient services and supplies physical and speech therapy and ambulance service. Policy Date until you reach age 90 and b when the same premium change is made on all in-force Medicare supplement policies of the same form issued to persons of your classification in the same geographic area of your state. Your policy s twoperson household premium discount ends if the person you live with terminates his or her policy or moves to a different residence. 2010 Medicare Supplement Insurance Plans Whether you re six or sixtysomething playing keeps you young-at-heart. The difference now of course is that you have adult responsibilities including making sound financial decisions. You ll probably enjoy playing however you define it even more when you feel you ve got your bases covered* You are covered immediately. There is no waiting period for preexisting conditions. Benefits will be paid from the time your policy is in force. Of Omaha Life Insurance Company can help you attain that secure feeling. Medicare Eligible Expenses means expenses of the kinds covered by Medicare Parts A and B to the extent recognized as reasonable and medically necessary by Medicare. A Benefit Period begins the first full day you are hospitalized and ends when you have not been in a hospital or skilled nursing facility for 60 days in a row. Since 1926 United of Omaha Life Insurance Company offers a diversified portfolio of life insurance fixed annuities and When you own a United of Omaha Medicare supplement you get the reputation stability and power of Mutual of Omaha and its affiliates which have been providing quality products and services since 1909. Any expense incurred before your Policy Date expense paid for by Medicare Coinsurance is the portion of the eligible expense not paid by Medicare and paid by United of Omaha* As Medicare deductibles and coinsurance increase your Medicare supplement benefits will automatically increase. Benefits are not paid for any expense paid by Medicare. Benefits are paid to you or to your hospital or doctor. You have 31 days from your renewal date to pay your premium* Your policy will stay in force during this 31-day grace period. Your policy is guaranteed renewable. Your policy cannot be canceled* It will be renewed as long as the premiums are paid on time and the information is correct on the application* You cannot be singled out for a rate increase no matter how many times you receive benefits. Your premium changes a each year on the renewal date coinciding with or following the anniversary of your incurred during a Medicare Part A benefit period that begins while this policy is not in force services for non-Medicare eligible expenses services for which no charge is made when there is no insurance loss or expense that is payable under any other certificate Add our friendly personal customer service and affordable premiums including a discount for your eligible spouse or household resident and you have the financial value and security you seek. This is a brief description of your coverage. The outline of coverage must accompany this brochure. For complete information on benefits exceptions limitations and reductions please read your outline of coverage and your policy. This is a solicitation of insurance and an insurance agent will contact you by telephone. We ve got you covered* Neither United of Omaha Life Insurance Company nor its Medicare supplement insurance policies are connected with or endorsed by the U*S* government or the federal Medicare program* United of Omaha except in NY. Go play is underwritten by Insurance Company UC7169OR Oregon Policy Form UM1-21306 Plan A Omaha NE 68175 mutualofomaha*com Choose the Medicare Supplement Plan That Meets Your Needs Services and Supplies Hospital Coverage Deductible First 60 days 61-90 days 91-150 days Lifetime Reserve Extended Hospital Coverage up to an additional 365 days in your lifetime Benefit for Blood Facility Care 21-100 days Pays Nothing All but a day three pints Supplement Plan A Plan F Plan G Eligible Expenses Three pints 137. 50 Up to Additional Benefits Emergency Care Received Outside the U*S* At-home Recovery Visits up to Medicare s limit 80 to lifetime max of 50 000 Your Premium Refer to the next page and your outline of coverage for more information* Deductible Plans F and G pay the 1 100 inpatient Services and Supplies hospital deductible for each benefit period. First 60 Days After the Medicare Part A deductible Medicare pays all eligible expenses for services from your first through 60th day of hospital confinement. Nursing and miscellaneous hospital services and supplies. you are hospitalized from the 61st through the 90th day. And when you are in the hospital from the 91st day through the 150th day you receive 550 a day for each Lifetime Reserve day used* the hospital longer than 150 days during a benefit period and you have exhausted your 60 days of Medicare Lifetime Reserve Plans A F and G pay the paid at the Diagnostic Related Group DRG day outlier per diem or other appropriate standard of payment subject to a lifetime maximum benefit of an additional 365 days. First three pints needed* Plans A F and G pay this Medicare Part B Physician s Excess Benefits First 20 Days Medicare pays all eligible expenses. A day from the 21st through the 100th day during which you receive skilled nursing care. You must enter a Medicare-certified skilled nursing facility within 30 days of being hospitalized for at least three days. Coinsurance After the Medicare Part B deductible Plans A F and G pay 20 of eligible expenses for physician s services and supplies physical and speech therapy and ambulance service. For hospital outpatient services the copayment amount will be paid under a prospective payment system* If this system is not used then 20 of eligible expenses will be paid* and Plan G pays 80 of the difference up to the charge limitation established by Medicare. This deductible. you pay a 250 calendar-year deductible Plans F and G pay you 80 of eligible expenses incurred during the first 60 days of a trip up to a lifetime maximum of 50 000. Benefits are payable for health care you need because of a covered injury or illness. visits a week up to 40 a visit up to a maximum of 1 600 a year for assistance with activities of daily living. Benefits are payable for services necessary for your continuing recovery from an illness injury or surgery.

Preferred risk policy fema for... TABLE OF CONTENTS PREVIOUS SECTION NEXT SECTION PREFERRED RISK POLICY I. when contents basement. GENERAL DESCRIPTION The Preferred Risk Policy PRP offers low-cost coverage to owners and tenants of eligible buildings located in the moderate-risk B C and X Zones in NFIP Regular Program communities. C. in a Loss History 2 flood insurance claim payments each more than 1 000 or 3 or more flood insurance claim payments regardless of amount or 2 Federal flood disaster relief payments including loans and grants each more than 1 000 or amount or ELIGIBILITY REQUIREMENTS 1 000. Flood Zone To be eligible for building/contents coverage or contents-only coverage under the PRP the building must be in a B C or X Zone on the effective date of the policy. The flood map available at the time of the renewal offer determines a building s continued eligibility for the PRP. NFIP map grandfathering rules do not apply to the PRP. B. entirely Only one building can be insured per policy and only one policy can be written on each building. A. located A building s eligibility for the PRP is based on the preceding requirements and on the building s flood loss history. If one of the following conditions exists regardless of any change s in ownership of the building then the building is not eligible for the PRP The maximum one- to four-family residential coverage combination is 250 000 building and 100 000 contents. Up to 100 000 contentsonly coverage is available for other residential properties. The maximum non-residential coverage combination is 500 000 building and II. Are D. Exclusions The PRP is not available in Special Flood Hazard Areas or in Emergency Program Other residential properties are not eligible for building coverage. Contents located entirely in a basement are However contents located entirely in an enclosure are eligible. Occupancy Combined building/contents amounts of insurance are available for owners of singlefamily two- to four-family and non-residential properties. Combined building and contents coverage is not available for other residential* and owners of all eligible occupancies except THE PRP AT A GLANCE OCCUPANCY/MAXIMUM LIMITS POLICY TYPE 1-4 Family Non-Residential Combined Building/ Contents 250 000/ 100 000 No Coverage Contents Only NOTES Condominium associations are not eligible for the Preferred Risk Policy. Individual condominium units are not eligible unless they qualify under one of the exceptions on page PRP 2. PRP 1 May 1 2005 VI. REPLACEMENT COST COVERAGE Condominium associations unit owners and their tenants are not eligible for the PRP except for - A townhouse/rowhouse building insured under the unit owner s name - A detached single-family dwelling insured under the unit owner s name. Occupying townhouse/rowhouse buildings or detached single-family dwellings. Replacement cost coverage applies only if the building is the principal residence of the insured and the building coverage chosen is at least 80 percent of the replacement cost of the building at the time of the loss or the maximum coverage available under the NFIP. VII. DISCOUNTS/FEES/ICC PREMIUM Increased Cost of Compliance ICC units. See footnote 3 on page PRP 3. DOCUMENTATION All Preferred Risk Policy new business applications must include documentation of eligibility for the PRP. Such applications must be accompanied by one of the following A Letter of Map Amendment LOMA A Letter of Determination Review LODR A copy of the most recent flood map marked to show the exact location and flood zone of A letter indicating the exact location and flood zone of the building and signed and dated by a local community official An elevation certificate indicating the exact location and flood zone of the building and signed and dated by a surveyor engineer architect or local community official A flood zone determination certification that guarantees the accuracy of the information* VIII. DEDUCTIBLES The standard deductible for PRPs is 500. Optional deductibles are not available for PRPs. IX. ENDORSEMENTS The PRP may be endorsed to Increase coverage mid-term subject to the coverage limits in effect when the policy was issued or renewed* See page END 5 for an example. Correct misratings such as incorrect building description or community number. X. CONVERSION OF STANDARD RATED POLICY TO PRP DUE TO MISRATING A policy written as a Standard B C or X Zone policy and later found to be eligible for a PRP may be endorsed or rewritten as a PRP for only the current policy term* An agent writing through a Write Your Own WYO company should contact that company for guidance. IV. RENEWAL When the risk has been rated with other than B C or X Zone rates but is later found to be in a B C or X Zone and eligible for a PRP the writing company will be allowed to endorse or cancel/rewrite up to 6 years. An eligible risk renews automatically without submission of a new application* If during a policy term the risk fails to meet the eligibility requirements it will be ineligible for renewal as a PRP. Such a risk must be nonrenewed or rewritten as a conventional Standard Flood Insurance Policy SFIP. V. No Community Rating System discount is associated with the PRP. Probation fees will be charged* The Federal Policy Fee of 11. 00 is included in the premium and is not subject to commission* The ICC premium is included* The policy may be canceled/rewritten using Cancellation Reason Code 22 if both of the following conditions are met The request to endorse or cancel/rewrite the policy is received during the current policy term* The policy has no open claim or closed paid claim on the policy term being canceled* COVERAGE LIMITS The elevated building coverage limitation provisions do not apply to a policy written as a PRP. PRP 2 October 1 2005 PRP COVERAGES AVAILABLE EFFECTIVE MAY 1 2004 ONE- TO FOUR-FAMILY RESIDENTIAL BUILDING AND CONTENTS COVERAGE COMBINATIONS With Basement or Enclosure Without Basement or Enclosure Building Premium2 3 30 000 12 000 75 000 40 000 60 000 80 000 ALL RESIDENTIAL CONTENTS-ONLY COVERAGE Contents Above Ground Level More Than One Floor All Other Locations Basement-Only Not Eligible NON-RESIDENTIAL BUILDING AND CONTENTS COVERAGE COMBINATIONS Add the 50. 00 Probation Surcharge if applicable. Premium includes Federal Policy Fee of 11. 00. eligible unless they qualify under one of the exceptions on page PRP 2. The deductibles apply separately to building and contents. Building deductible 500. Contents deductible 500. PRP 3 The new PRP building and/or contents coverage will be equal either to the building limit issued under the Standard B C or X Zone policy or the next higher limit available under the PRP if there is no PRP option equal to the Standard B C or X Zone building limit* For a standard contentsonly policy the contents coverage will be equal to the limit issued under the standard policy or the next higher limit* If building coverage is desired the policy should be endorsed for building and contents coverage with a 30-day waiting period applied* First Mortgagee section* If BILL SECOND MORTGAGEE BILL LOSS PAYEE or BILL OTHER is checked provide mailing instructions in Second Mortgagee or Other section* XI. CONVERSION OF STANDARD RATED REVISION LOMA OR LOMR Enter the policy effective date and policy expiration date month-day-year. The adding the appropriate waiting period to the date of application in the Signature section* The standard waiting period is 30 days. Refer to the General Rules Section page GR 7 for the applicable waiting period. Agent Information A standard rated policy may be canceled and rewritten as a PRP as a result of a map revision LOMA or LOMR if the effective date of the map change was on or after February 1 2005. Enter the agent s producer s name agency name and number address city state ZIP Code telephone number fax number and Tax I. D. Number or Social Security Number. newly established Cancellation Reason Code 24 under the following conditions policy must be received during the policy term or within 6 months of the policy The standard policy has no open claim or closed paid claim on the policy terms being canceled* The property meets all other PRP eligibility Insured s Mailing Address Enter the name mailing address city state ZIP Code telephone number and Social Security Number of the insured* If the insured s mailing address is a post office box or a rural route number or if the address of the property to be insured is different from the mailing address complete the Property Location section of the application* E* Disaster Assistance Check YES if flood insurance is being required for disaster assistance. Enter the insured s case file number Tax I. D. Number or Social Security Number on the line for CASE FILE NUMBER* In the Second Mortgagee or Other block identify the government disaster agency and enter the complete name and mailing address of the disaster agency. If NO is checked no other information is required* F* The building and/or contents coverage on the new PRP must be equal either to the building limit and/or contents limit issued under the standard policy or to the next higher limit option equal to the standard policy building and/or contents limit* XII. COMPLETING THE FLOOD INSURANCE Policy Status In the upper right corner of the form check the appropriate box to indicate if the application is for a NEW policy or a RENEWAL of an existing policy. If the application is for a renewal enter the current NFIP policy number. first mortgagee. Enter the loan number. Policy Term G* Check the appropriate box to indicate who should receive the renewal bill* If BILL FIRST MORTGAGEE is checked complete PRP 4 Second Mortgagee or Other The PRP is available only for 1-year terms. Identify additional mortgagees by checking the appropriate box and entering the loan number mortgagee s name mailing address telephone number and fax number. If more than one additional mortgagee or the requested information on the producer s letterhead* H. Property Location Check YES if the location of the property being insured is the same as the address entered in the Insured s Mailing Address section* Leave the rest of this section blank unless there is more than one building at the property location* Check the Y box YES or the N box NO for CONDO UNIT and TOWNHOUSE/ROWHOUSE CONDO UNIT. Check location of building s contents. are not eligible for contents-only coverage. principal residence otherwise check NO. Using normal company practice estimate the replacement cost value and enter the value in the space provided* Include the cost of the building foundation when determining the replacement cost value. K. Notice type is a manufactured mobile home/ travel trailer on foundation enter the make model and serial number in the block at the bottom of this section* of the insured property use this section to specifically identify the building to be insured* Briefly describe the building or submit a sketch showing the location of insured buildings to assist the NFIP in matching the policy number to the specific building insured* If NO provide the address or location of the property to be insured* If the answer to either question A or question B is YES this risk is not eligible for the Preferred Risk Policy. Street address legal description or geographic location of the property. Enter the community identification number map panel number and revision suffix for the community where the property is located* Use the FIRM in effect and that has been published at the time of presentment of premium and completion of application* Community number and status may be obtained by calling the writing company consulting a local community official or referencing the NFIP Community Status Book online at www. Fema*gov/fema/csb*shtm* A credit card payment by VISA MasterCard Diner s Club or American Express will also be acceptable if a disclaimer form signed by the insured is submitted with the Preferred Risk Policy Application* The disclaimer will state that cancellation of a policy due to a billing dispute will be permitted only for a billing error or fraud. If the credit card information is taken over the telephone by the producer the producer may sign the authorization form on behalf of the payor only after having read the disclaimer to the payor. Complete all required information in this section* Check building occupancy Single Family 2-4 Family Other Residential or NonResidential incl* Hotel/Motel. Enter date of construction* Signature The producer must sign the Preferred Risk completeness and accuracy of the information provided on it. Enter the date of application month/day/year. The waiting period is added to this date to determine the policy effective date of the policy listed in the Policy Term section* A check or money order for the Total Prepaid Amount payable to the NFIP must accompany Enter the Flood Insurance Rate Map zone. J* applicable. Deduct 1. 00 if this is an application for a townhouse/rowhouse condominium unit. M. Unincorporated area of a county otherwise check NO. Enter the coverage selected and the premium from the appropriate table on the back of the application form* Enter the name of the county or parish where the property is located* Community L* basement or enclosure count the basement or enclosure as a floor.

Personal lines renewal policy... Vermont An agent's guide to Harleysville's Harleysville agents have been quoting and rating new personal lines auto and homeowners business via accessHarleysville//PL since 2008, and we're ready now

Policy series p19872 critical... Policy Series P19872 CRITICAL ILLNESS INDEMNITY INSURANCE The premium paid, the completed application, and Our reliance on the answers to the application questions have put this policy in force as

Your privacy rights huntington... Your Privacy Rights Huntington's Online Privacy Policy Huntington's Online Privacy Policy ('Online Policy') applies to The Huntington National Bank and its affiliates (collectively described

Policy change request form wea... Policy Change Request Form Please submit this form and all related correspondence to: WEA, Ltd. Customer Service: +1.305.405.8929 USA Toll Free: +1.800.222.3002 Int l Toll Free: +1.844.596.2729 Email:

Graduation clearance direction... GRADUATION CLEARANCE DIRECTIONS RETURN FORM TO: Office of the Registrar 130 Coffey Hall 1420 Eckles Ave St. Paul, MN 55108 6126264432 (fax) 6126254351 On campus: 130 Coffey Hall Graduation clearance

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