Insurance | airSlate SignNow

Form seized asset claim DEPARTMENT OF HOMELAND SECURITY U.S. Customs and Border Protection SEIZED ASSET CLAIM FORM Request for Forfeiture Proceedings in Federal Court IMPORTANT This form should be used only if you want your case referred to the United States Attorneys Office to decide your case in Federal Court. DO NOT COMPLETE THIS FORM if you want U*S* Customs and Border Protection to handle your case administratively. Name Seizure No* Address Telephone No* INSTRUCTIONS You must complete all three parts below. As authorized by 18 USC 983 a 2 A I request that the Government file a complaint for forfeiture in Federal Court against the seized property described below Part I List all the items in which you claim an interest. Include sufficient information to identify the items such as serial numbers make and model numbers aircraft tail numbers photographs and so forth. Use continuation sheet if more space is needed* State your interest in each item of property listed above. Use continuation sheet if more space is needed* Part III ATTESTATION AND OATH I attest and declare under penalty of perjury that the information provided in support of my claim is true and correct to the best of my knowledge and belief* Printed Name Signature Date A FALSE STATEMENT OR CLAIM MAY SUBJECT A PERSON TO PROSECUTION UNDER 18 U*S*C. 1001 AND/OR 1621 AND IS PUNISHABLE BY A FINE AND UP TO FIVE YEARS IMPRISONMENT. CBP Form 4631 07/07 CONTINUATION SHEET Seizure Case Number Full Name First Middle Last. DO NOT COMPLETE THIS FORM if you want U*S* Customs and Border Protection to handle your case administratively. Name Seizure No* Address Telephone No* INSTRUCTIONS You must complete all three parts below. As authorized by 18 USC 983 a 2 A I request that the Government file a complaint for forfeiture in Federal Court against the seized property described below Part I List all the items in which you claim an interest. Name Seizure No* Address Telephone No* INSTRUCTIONS You must complete all three parts below. As authorized by 18 USC 983 a 2 A I request that the Government file a complaint for forfeiture in Federal Court against the seized property described below Part I List all the items in which you claim an interest. Include sufficient information to identify the items such as serial numbers make and model numbers aircraft tail numbers photographs and so forth. Include sufficient information to identify the items such as serial numbers make and model numbers aircraft tail numbers photographs and so forth. Use continuation sheet if more space is needed* State your interest in each item of property listed above. Use continuation sheet if more space is needed* State your interest in each item of property listed above. Use continuation sheet if more space is needed* Part III ATTESTATION AND OATH I attest and declare under penalty of perjury that the information provided in support of my claim is true and correct to the best of my knowledge and belief* Printed Name Signature Date A FALSE STATEMENT OR CLAIM MAY SUBJECT A PERSON TO PROSECUTION UNDER 18 U*S*C.

City of los angeles claims for... OFFICE OF THE CITY CLERK City of Los Angeles Claims for Damages Form Please mail the original signed form to (copies and faxes not accepted): Address: Office of the City Clerk 200 North Spring Street

Wage claim form iowa workforce... Terry E. Branstad, Governor Kim Reynolds, Lt. Governor Michael A. Mauro, Labor Commissioner IOWA DEVELOPMENT Smart. Results. Division of Labor Services IMPORTANT - READ CAREFULLY The Division of Labor

Aetna student health claim for... Medical Benefits Claim Instructions Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of

Carefirst health benefits clai... I the undersigned authorize CareFirst BlueChoice Inc. to make payment for benefits due herein to Name of Provider Provider s Tax or Social Security Number Subscriber Signature Date Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. CareFirst BlueChoice Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland Inc. 1F1-19211F 3/12 INSTRUCTIONS THIS FORM IS TO BE USED TO SUBMIT A CLAIM FOR SERVICES RENDERED UNDER YOUR CAREFIRST BLUECHOICE INC. HEALTH PLAN. THE BLUECHOICE PROVIDER IS RESPONSIBLE FOR SUBMITTING CLAIMS FOR IN-NETWORK SERVICES. TO AVOID HAVING YOUR CLAIM RETURNED 3 PREPARE A SEPARATE CLAIM FORM FOR EACH FAMILY MEMBER. 3 COMPLETE ALL OF THE INFORMATION REQUESTED IN ITEMS 1 THRU 18. 3 IF YOU PREFER THAT BENEFITS BE PAID TO THE PROVIDER OF SERVICE BE SURE TO COMPLETE THE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS ON THE FRONT. I authorize any physician nurse hospital or other providers or suppliers in possession of information concerning the patient to furnish such information to CareFirst BlueChoice Inc. upon request. I the undersigned authorize CareFirst BlueChoice Inc. to make payment for benefits due herein to Name of Provider Provider s Tax or Social Security Number Subscriber Signature Date Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. CareFirst BlueChoice Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland Inc. 1F1-19211F 3/12 INSTRUCTIONS THIS FORM IS TO BE USED TO SUBMIT A CLAIM FOR SERVICES RENDERED UNDER YOUR CAREFIRST BLUECHOICE INC. HEALTH PLAN. THE BLUECHOICE PROVIDER IS RESPONSIBLE FOR SUBMITTING CLAIMS FOR IN-NETWORK SERVICES. TO AVOID HAVING YOUR CLAIM RETURNED 3 PREPARE A SEPARATE CLAIM FORM FOR EACH FAMILY MEMBER. 3 COMPLETE ALL OF THE INFORMATION REQUESTED IN ITEMS 1 THRU 18. HEALTH BENEFITS CLAIM FORM PLEASE COMPLETE A SEPARATE CLAIM FORM FOR EACH FAMILY MEMBER* SEE REVERSE SIDE FOR FILING INFORMATION PROCESSING YOUR CLAIM PLEASE TYPE OR PRINT 1. MEMBER ID 2. GROUP NUMBER OR ENROLLMENT CODE 3. PATIENT S NAME FIRST MIDDLE INITIAL LAST 4. PATIENT S DATE OF BIRTH 5. PATIENT S SEX 6. PATIENT S RELATIONSHIP TO SUBSCRIBER EE SP CH MO DAY YEAR q FEMALE MALE SELF SPOUSE 7. SUBSCRIBER S NAME FIRST MIDDLE INITIAL LAST 10. IS PATIENT COVERED UNDER OTHER HEALTH INSURANCE NO YES EXPLAIN NO IF THE SUBSCRIBER IS MARRIED IS THE SPOUSE EMPLOYED NO IF YES GIVE THE NAME OF THE SPOUSE S EMPLOYER MEDICARE HIC NUMBER IS PATIENT ACTIVELY EMPLOYED NO MEDICAL EMERGENCY NO IF YES NAME OF EMPLOYER 2 AUTO ACCIDENT NO 11.

Blue cross blue shield of alab... MEDICAL EXPENSE CLAIM An Independent Licensee of the Blue Cross and Blue Shield Association. FILL OUT A SEPARATE FORM FOR EACH PATIENT. Use this form to file a claim for any eligible medical expenses

Claim for damages against metr... 96. 020 and may be subject to public disclosure. Present in Person or Mail the Claim for Damages Form and Supporting Documents to mail or certified mail with return receipt requested to the following City of Tacoma City Clerk s Office 747 Market Street Suite 220 Tacoma WA 98402 Business Hours Monday-Friday 8 00 a.m. to 5 00 p.m. Closed on weekends and holidays. Please attach any documents of documents that support the claim s allegation. Remember to keep a copy as submitted material will not be returned. costs property damage loss etc. This amount should represent your opinion of total compensation. Please sign date and place the bottom of page 2 before submitting your claim. CITY OF TACOMA CLAIM FOR DAMAGES FORM For Official Use Only General Liability Claim Form Pursuant to Chapter 4. 18. Please attach documents which support the claim s allegations. 19. I claim damages from the City of Tacoma in the sum of. This Claim form must be signed by the Claimant a person holding a written power of attorney from the Claimant by an attorney admitted to practice in Washington State on the Claimant s behalf or by a court-approved guardian or guardian ad litem on behalf of the Claimant. Attach additional sheets if necessary. 16. Has this incident been reported to law enforcement safety or security personnel If so when and to whom and billings. 18. Please attach documents which support the claim s allegations. 19. I claim damages from the City of Tacoma in the sum of. The following are examples on how to complete the Claim for Damages Form Smith Karen Michelle 05/09/1974 1234 College Way NW Apt. 56 Tacoma WA 98402 PO Box 910 Tacoma WA 98402 Same or residence at the time of incident 253 123-4567 ksmith email.com 08/02/2009 8 00 a.m. Washington Pierce Tacoma Tacoma Public Utilities parking lot I-5 Southbound Milepost 109 near the Martin Way Exit OR South 50th and G Streets Tacoma Power Smith Thomas Arthur 1234 College Way NW Apt. CLAIM FOR DAMAGES FORM PACKET Please carefully read all of the information in this packet before completing and presenting your Claim for Damages form* Documents Contained in the Claim for Damages Form Packet Instructions for completing the Claim for Damages form Claim for Damages form Legal Requirements for Presenting Claim for Damages Form In order to verify the claim and additional supporting information the law requires that the The Claimant or A person who has been given authority by the Claimant under a written power of attorney or An attorney admitted to practice in Washington State on the Claimant s behalf or A court-approved guardian or guardian ad litem on behalf of the Claimant. Important State law requires an original signature on the Claim for Damages form* This means that claim forms cannot be submitted electronically fax or e-mail. The length of the Claim for Damages investigation varies greatly depending on the complexity of the issues and the availability of evidence to support the claim* A Claim for Damages can be resolved and closed quicker when all relevant information and documents are provided initially for the City s consideration* Some of the information requested on this form is required by RCW 4.

Cbiz form CBIZ Flex Flexible Benefits Plan Claim Form Version 11. 01. 08 Employer Email SSN Phone - Un-reimbursed Medical Expense Claims Date Expense Incurred Name of Service Provider Expense Description Person for Whom Expense Incurred Net Amount Attach appropriate receipt s and submit with this claim form. Total Medical Care Expense Claim Dependent Care Expense Claims Name of Dependents Period Covered From To Name and Taxpayer Identification Number of Service Provider Amount Incurred Total Dependent Care Expense Claim Provider s Signature Read Carefully The undersigned participant in the Plan certifies that all expenses for which reimbursement or payment is claimed by submission of this form were incurred during a period while or are not reimbursable under any other health plan coverage and that they were incurred by the participant or a legal dependent of the participant. The expenses qualify as valid Medical Care Expenses under Code 213 d as defined in the Flexible Spending Account Summary Plan Description Document the plan. The undersigned certifies that their family member has received the services described above on the dates indicated and the expenses qualify as valid Dependent Care Expenses as defined in the FSA Summary Plan Description Document. The undersigned fully understands that he or she is fully responsible for the sufficiency accuracy and veracity of all information relating to this claim which is provided by the undersigned and that unless an expense for which payment or reimbursement is claimed is a proper expense under the Plan the undersigned may be liable for payment of all related taxes including federal state and or local income tax on amounts paid from the Plan which relate to such expense. Employee Signature Date Claim Forms can be mailed or faxed to CBIZ Payroll Attn Flex 310 First St* Ste 600 Roanoke VA 24011 Please keep a copy for your records Fax 800-584-4185 Phone 800-815-3023 option 4 Email cbizflex cbiz. The expenses qualify as valid Medical Care Expenses under Code 213 d as defined in the Flexible Spending Account Summary Plan Description Document the plan. The undersigned certifies that their family member has received the services described above on the dates indicated and the expenses qualify as valid Dependent Care Expenses as defined in the FSA Summary Plan Description Document. The undersigned certifies that their family member has received the services described above on the dates indicated and the expenses qualify as valid Dependent Care Expenses as defined in the FSA Summary Plan Description Document. The undersigned fully understands that he or she is fully responsible for the sufficiency accuracy and veracity of all information relating to this claim which is provided by the undersigned and that unless an expense for which payment or reimbursement is claimed is a proper expense under the Plan the undersigned may be liable for payment of all related taxes including federal state and or local income tax on amounts paid from the Plan which relate to such expense.

Adp health care fsa flexid cla... Tips to Remember when submitting Health Care FSA expenses. 1. Include your 10-digit FlexID. Locate your FlexID at www. flexdirect. adp.com or by calling the Participant Solution Center at 1-800-654-6695. 2. Sign Date and Fax your Claim Form without a cover page followed by a copy of all supporting documentation including itemized receipts bill or statements and/or Explanation of Benefits EOB showing date provider amount and type of service. The t...

Samba claim form Mail SAMBA Claims To CIGNA P. O. Box 188007 Chattanooga TN 37422 301 984-1440 800 638-6589 HEALTH INSURANCE CLAIM FORM Instructions are shown on reverse side. MEDICAID Medicare CHAMPUS CHAMPVA Medicaid Sponsor s SSN VA File 2. PATIENT S NAME Last Name First Name Middle Initial GROUP HEALTH PLAN X FECA BLK LUNG OTHER SSN or ID SSN ID 3. PATIENT S BIRTH DATE MM DD YY 4. INSURED S NAME Last Name First Name Middle Initial F 6. PATIENT RELATIONSHIP TO INSURED Self CITY STATE Spouse Child 8. PATIENT STATUS Married Employed Full-Time Student Part-Time ZIP CODE 9. OTHER INSURED S NAME Last Name First Name Middle Initial 10. IS PATIENT S CONDITION RELATED TO a* EMPLOYMENT CURRENT OR PREVIOUS YES NO b. AUTO ACCIDENT SEX M Other TELEPHONE Include Area Code 7. INSURED S ADDRESS No* Street Single c* EMPLOYER S NAME a* INSURED S DATE OF BIRTH c* INSURANCE PLAN NAME OR PROGRAM NAME d. IS THERE ANOTHER HEALTH BENEFIT PLAN If yes return to and complete item 9 a-d 13. INSURED S OR AUTHORIZED PERSON S SIGNATURE* I authorize payment of medical benefits to the undersigned physician or supplier for services described below. Date ILLNESS First Symptom OR INJURY Accident OR PREGNANCY LMP 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE Signed 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS GIVE FIRST DATE 17a* 17b. NPI 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION FROM TO 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 20. OUTSIDE LAB 19. RESERVED FOR LOCAL USE 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate Items 1 2 3 or 4 to Item 24E by Line. CHARGES 22. MEDICAID RESUBMISSION CODE ORIGINAL REF* NO. PLACE State b. EMPLOYER S NAME 12. PATIENT S OR AUTHORIZED PERSON S SIGNATURE* I authorize the release of any medical or other information necessary to process this claim* 14. DATE OF CURRENT 11. INSURED S POLICY GROUP NUMBER c* OTHER ACCIDENT FOR PROGRAM IN ITEM 1 5. PATIENT S ADDRESS No* Street 1a* INSURED S I. D. NUMBER PATIENT AND INSURED INFORMATION 1. MEDICARE 24. A. From DATE S OF SERVICE To B. C. Place of Service EMG D. PROCEDURES SERVICES OR SUPPLIES Explain Unusual Circumstances CPT/HCPCS MODIFIER E* DIAGNOSIS POINTER F* G* H. I. DAYS EPSDT ID. Family OR UNITS Plan QUAL* J* RENDERING PROVIDER ID. NPI 25. FEDERAL TAX I. D. NUMBER SSN EIN 26. PATIENT S ACCOUNT NO. 27. ACCEPT ASSIGNMENT For govt. claims see back 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS I certify that the statements on the reverse apply to this bill and are made a part thereof* SIGNED 32. SERVICE FACILITY LOCATION INFORMATION DATE a* b. PLEASE PRINT OR TYPE 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE 33. BILLING PROVIDER INFORMATION PHONE PHYSICIAN OR SUPPLIER INFORMATION 23. PRIOR AUTHORIZATION NUMBER 1. Complete items 1 through 13. 2. Attach itemized bills to the Claim Form* You do not need to have the provider of service complete the claim form if you attach fully itemized bills and/or receipts. Bills and receipts must show Name of patient and relationship to member Plan identification number of the member Name and address of physician or supplier providing the service or supply Date service or supply was furnished Type of service or supply and the charge Diagnosis In addition A copy of the Explanation of Benefits from any primary payer such as Medicare must be sent with your claim* Claims for rental or purchase of durable medical equipment private duty nursing and physical occupation and speech therapy require a written statement from the doctor specifying the medical necessity for the service or supply and the length of time needed* Claims for overseas foreign services should include an English translation* Charges should be converted to U*S* dollars using the exchange rate applicable at the time the expense was incurred* Cancelled checks cash register receipts or balance due statements are not acceptable.

Clico medical claim form MAIL TO: COMBINED LIFE INSURANCE COMPANY OF NEW YORK Administrative Concepts, Inc. 994 Old Eagle School Road Suite 1005 Wayne, PA 19087-1802 www.visit-aci.com BOTH SIDES OF CLAIM FORM MUST BE COMPLETED

Health insurance claim form 15... Revised Health Insurance Claim Form CMS-1500 (GEN) Posted April 5, 2006 The Form CMS-1500 (12-90) is being revised to accommodate the reporting of the National Provider Identifier (NPI). The work

Insurance forms

Browse over 85,000 state-specific fillable forms for all your business and personal needs. Customize legal forms using advanced airSlate SignNow tools.

Get legally binding signatures now!