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Dms aviation insurance policy... DMS' AVIATION INSURANCE POLICY ENDORSEMENT FORM Agency Name and Mailing Address Contact Person Telephone Number Coverage Endorsement Effective Date Quote Only Aircraft Information Year Make Model

Aviation insurance policy endo... This form is used to endorse coverage for aviation insurance, including details about specifics such as aircraft information, liability and hull coverage, and effective dates.

Group life insurance policy fo...

Quick issue term change applic... Print Have you checked your default printing preferences? Manlike Quick Issue Term Application for change when evidence of insurability is required Use this form to make a change to a Manlike Quick

Insurance policy schedule form 1 2 3 Lowell Finley, SON 104414 LAW OFFICES OF LOWELL FINLEY 1604 SOLANO AVENUE BERKELEY, CALIFORNIA 94707-2109 TEL: 510-290-8823 FAX: 510-526-5424 4 Attorneys for Plaintiffs and Petitioners 5 SUPERIOR

Request for life insurance pol... Enforce Illustration Request Form Request for life insurance policy information to: Insurance Company: Address: Fax: () Phone: () Regarding Policy owner: Policy number(s):, I, the policy owner, request

Insurance request form We den y this request. When do we complete this form Complete Part A of this form whenever an employee asks you to IF the employee is eligible for life insurance see below. OFEGLI must receive the form within 60 days of the date of the physical. Do I have to pay for this physical Yes you must pay any fee for the physical. Your agency or OFEGLI cannot pay for it. Can I use results of a physical I had last year for another reason No. OFEGLI cannot accept a previous physical. Your physician or other healthcare provider must perform the physical for the purposes of this request for life insurance. Can I use results of a physical I had last year for another reason No. OFEGLI cannot accept a previous physical. Your physician or other healthcare provider must perform the physical for the purposes of this request for life insurance. OFEGLI must receive this form within 60 days of the date of the physical. What is Basic insurance It is life insurance based on your annual salary rounded up to the nearest thousand dollars if it is not already an even thousand plus 2 000. Each SF 2817 you complete replaces the previous form. You must sign for all coverage you currently have and wish to keep AND you must sign for all new coverage you wish to elect. If you have coverage now and do not sign for that coverage you have cancelled that coverage. Can I appeal OFEGLI s decision is final. There are no formal appeal procedures. You or your physician or other healthcare provider may call OFEGLI at 1-800-633-4542 and ask why it denied your request for insurance. Request For Insurance Federal Employees Group Life Insurance FEGLI Program Instructions for Employees When should I complete this form You should complete this form if you are in a position that makes you eligible for FEGLI coverage ask your human resources office if you don t know AND at least one year has passed since the effective date of your most recent waiver of Basic Option A and/or Option B life insurance AND either you are not enrolled in the FEGLI Program but would like to be OR you are enrolled in the FEGLI Program but you have less than the maximum life insurance available and you want more life insurance. OFEGLI contacts request. You should contact your human resources office if it is more than 2 weeks after the date your physician or other know whether OFEGLI approved your physical. My agency told me that OFEGLI approved my request. What do I do If you just want Basic insurance you do not have to do anything. You will automatically have it on the first day you are in a pay and duty status on or after the date of OFEGLI s approval as long as you are in a pay and duty status within 60 days of OFEGLI s approval. If you want Option A and/or Option B you must complete SF 2817 Life Insurance Election. Your human resources office must receive your form within 60 days after OFEGLI s approval. Sign for Basic and for Option A and/or Option B. What is a waiver of life insurance coverage A waiver means you did not elect life insurance coverage when it was available to you OR cancelled coverage you previously had OR elected less than the maximum coverage.

Request alternate base period... Department of Labor PO Box 15130 Albany New York 12212-5130 www. labor. ny. gov Unemployment Insurance Request for Alternate Base Period Please print clearly IMPORTANT We sent you a Monetary Benefit Determinations showing the weekly benefits you will receive. Those benefits are based on your wages. If you believe some of your wages were missed please complete this form* This form must be received by us within 10 calendar days of the Date Mailed as stated on your most recent Monetary Benefit Determination notice. Please print clearly. If we cannot read your writing we cannot process this form* Last Name First Name Middle Initial Address City State Zip Code Claim Effective/Start Date // Social Security XXX XX - Form requirements If you wish to use the Alternate Base Period to increase your weekly benefit rate Complete the steps below using black or blue ink. Include any documentation that could be considered proof of employment and wages such as pay stubs W-2s 1099s vouchers checks tips bonuses meals lodging commissions vacation pay and records of employment and/or payment. Photocopy all supporting documentation onto 8 x 11 single-sided paper. Do not send originals. Write your name the last four digits of you Social Security number and your phone number on each attachment. This completed form and all attachments must be received by the Response Due Date noted above. If the wages in your last completed calendar quarter exceed the High Quarter Wages on your Monetary Benefit Determination use of the Alternate Base Period may increase your benefit rate. If you choose the Alternate Base Period to establish a claim you will not be able to use these wages for a future claim* Step 1 Last Calendar Quarter Information The last completed calendar quarter prior to your claim effective/start date is // through // Step 2 Wage Complete the information below include proof of wages and attach an additional page if you have information for more than 3 three employers. Month/Day/Year Refer to your Monetary Benefit Determination for calendar quarter dates and compare the Alternate Base Period Quarter wages with your records then check the appropriate box below and proceed to the Step indicated* The Alternate Base Period Quarter Wages are incorrect or missing* Proceed to Step 2 Employer Name Quarterly Gross Wages Employer Address If work was performed outside New York State indicate state Step 3 I certify that the above information is true to the best of my knowledge and I am aware that there are penalties for making Acknowledgement false statements. I understand if I use the Alternate Base Period these wages cannot be used for a future claim* - - Signature Required Date Area Code Telephone Number Step 4 Return Instructions This notice and all attachments must be received within the time frame noted above in the IMPORTANT message. FAX 518 457-9378 OR MAIL New York State Department of Labor This notice is your cover page. Indicate total of pages Claim weekly benefits at www.

Usa archery certificate of ins... USA ARCHERY CERTIFICATE OF INSURANCE REQUEST FORM. NAME INSURED INFORMATION (If requesting on behalf of a USA Archery Club, please list ...

Louisiana department of insura... Louisiana Department of Insurance Request for Waiver of Examination for Workers Compensation Adjuster Pursuant to 22:1669 (C), individuals who have three years of verifiable experience adjusting workers

Wsib optional insurance reques... Optional Insurance Request/Change Mail To: 200 Front Street West Toronto ON M5V 3J1 Please complete this section. Account No. Address Firm No. Start Here Telephone Inquiry Number 416-344-1000 1-800-387-0750

Certificate of insurance reque... CERTIFICATE HOLDER Name/Entity Address Did the venue request to be listed as an additional insured Yes/No Complete one form for each COI request. Contact insurance wftda.com if you have any questions. Note Emergency Action Plans are due within 30 days of obtaining coverage. WFTDA Certificate of Insurance Request Form To obtain your Certificate of Insurance COI please complete ALL information requested and submit to insurance wftda.com. Allow a minimum of three business days for processing for requests submitted from December to January allow up to LEAGUE INFORMATION League Name LEAGUE MAILING ADDRESS Business or PO box strongly recommended Street Address Street 2 City ST ZIP I have verified the venue is compliant with Risk Management Guidelines enter initials here If your venue has requested a COI listing them as a certificate holder and/or additional insured you must also provide the following information. Provide exactly what the venue specifies as the certificate holder and/or additional insured this information is usually located in your contract or lease agreement. CERTIFICATE HOLDER Name/Entity Address Did the venue request to be listed as an additional insured Yes/No Complete one form for each COI request. Contact insurance wftda*com if you have any questions. Note Emergency Action Plans are due within 30 days of obtaining coverage. If your league hasn t submitted its EAP it will be requested at the time you submit your COI request. Contact insurance wftda*com if you have any questions. Note Emergency Action Plans are due within 30 days of obtaining coverage. If your league hasn t submitted its EAP it will be requested at the time you submit your COI request.

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