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2360 claim form pdf Illinois Department of Public Aid 201 South Grand Avenue East Springfield, Illinois 62763-0001 Rod R. Blagojevich, Governor Barry S. Maram, Director Telephone: (877) 782-5565 TTY: (800) 526-5812 April

Hcfa 2360 fill in form Currently in production on IEC for both DDE and Batch Processing 270 Transaction Recipient Eligibility Inquiry Request 276/277 transaction The following hardcopy claim format will be accepted in the MEDI IEC System effective March 21 2005 DPA 2360 Health Insurance Claim Form DPA 1443 Provider Invoice Claim Form DPA 2209 Transportation DPA 2210 Medical Equipment/Supplies Invoice DPA 215 Drug Invoice UB92 all claims currently submitted on th...

Met life dental claim form 200... Dental Expense Claim 1. Patient First Name Middle Last 2. Relationship to Employee 3. Sex Metropolitan Life Insurance Company 4. Married? 5. Patient Date of Birth 6. For Office Use Mo. / Day / Year

Aig life insurance life clains... Fidelity Life Association, A Legal Reserve Life Insurance Company/'The Company' Administrative Office: 1211 West 22nd Street, Suite 209 Oak Brook, IL 60523 (800) 369-3990 Claim Form - Life

Claim form m18979 GIRL SCOUTS OF THE U.S.A. CLAIM FORM Mail any additional bills Special Risk Services (properly identified by United of Omaha Life Insurance Company injured person and P.O. Box 31156 Council name)

New york life form for waiver... The Company you Keep New York Life Insurance Company Group Membership Association C laims 5505 West Cypress Street Tampa FL 33607 (800) 792 -9686 Dear Claimant: We are sorry to learn of your unfortunate

Tsgli claim form Must forward Parts A B to the member s branch of service TSGLI office listed on the front cover of this form. Page 1 COMPLETING THE FORM Instructions on completing the TSGLI Claim Form are included in each section. When completing the form the service member guardian power completing the form or if the member is deceased please contact the branch of service TSGLI office listed on the front cover of this form. Claim decision and payment Who Makes the Decision on My Claim Your branch of service TSGLI office will make the decision on your claim based upon the information in Parts A and B of the TSGLI Claim Form. They will then forward their decision to the Office of Servicemembers Group Life Insurance OSGLI for appropriate action. Who Will Receive the TSGLI Payment Payment will be made directly to the member. HOW TO FILE A TSGLI CLAIM Filing a TSGLI claim is a three-step process in which the service member or guardian power of attorney or military trustee and a medical professional must complete and submit the appropriate parts of the TSGLI Claim Form as follows Step 1 Step 2 Step 3 attorney or military trustee The medical professional guardian power of attorney or military trustee must complete Part A pages 3 through 6 of the form and give it to a medical professional to complete Part B. SERVICEMEMBERS GROUP LIFE INSURANCE TRAUMATIC INJURY PROTECTION PROGRAM TSGLI Administered by the Office of Servicemembers Group Life Insurance Application for TSGLI Benefits Please submit your completed claim to your branch of service below. TSGLI Branch of Service Contacts Branch Contact Information Submit Claim by Fax Army All Components Phone 800 237-1336 Website www. tsgli. army. mil 866 275-0684 tsgli conus. army. mil Army Human Resources Command Traumatic SGLI TSGLI 200 Stovall Street Alexandria VA 22332-0470 Marine Corps Phone 877 216-0825 or 703 432-9277 Website https //www. manpower. usmc* mil/pls/ portal/url/page/mrahome/wwr/ wwracommandelement/wwrdregimentalstaff/3s3/wwrtsgli 888 858-2315 t-sgli usmc*mil Attn WWR-TSGLI 3280 Russell Road Quantico VA 22134 Navy Phone 800 368-3202 / 901-874-2501 DSN 882 Website www. npc*navy. mil/Command Support/ CasualtyAssistance/TSGLI 901 874-2265 MILLTSGLI navy. mil Navy Personnel Command Attn PERS-62 5720 Integrity Drive Millington TN 38055-6200 Air Force Active Duty Phone 800 433-0048 Website ask. afpc*randolph. af*mil 210 565-2348 afpc*casualty randolph. af*mil AFPC/DPWC 550 C Street West Suite 14 Randolph AFB TX 78150-4716 Reserves Phone 800 525-0102 303 676-6255 arpc*dippedl arpc*denver. af*mil HQ ARPC/DPPE 6760 E Irvington Place 4000 Denver CO 80280-4000 Air National Guard Phone 703 607-0901 703 607-0033 tsgliclaims ngb. ang. af*mil NCOIC Customer Operations Air National Guard Bureau 1411 Jefferson Davis Hwy Suite 10718 Arlington VA 22202 Coast Guard Phone 202 475-5391 202 475-5927 compensation comdt. uscg. mil COMDT CG-1222 2100 2nd Street SW Washington DC 20593-0001 Public Health Services Phone 301 594-2963 301 594-2973 or 800 733-1303 compensationbranch psc*hhs.

Sglv 8283 form Check one WARNING mprisonment SGLV-8283 El One Sum CERTIFICATION made In thus claim are true to the best of my knowledge informatron and belief and that no evidence necessary In the event the Insured has not previously elected monthly Installments. CLAIM RETURN COMPLETED FORM TO OFFICE OF SERVICEMEMBERS GROUP LIFE INSURANCE INSURANCE 80 Livingston Avenue Roseland NJ 07068-1733 Newark New Jersey 07102-2999 FOR DEATH BENEFITS Servicemen s Group Life Insurance Servicemembers Group Life Insurance Veterans lOTE* THIS FORM IS NOT TO BE USED FOR NATIONAL SERVICE JNITED STATES GOVERNMENT USGLI Policy Numbers Prefixed NAME OF DECEASED LEASE READ THE IMPORTANT Comolete Items Policy Numbers INFORMATION AND INSTRUCTIONS 11A throuah ON REVERSE I- BEFORE 14C if vou are the widow CONCERNING or widower YES VOTE - ON0 Yes. complete If vou are not the named and 14c beneficiarv* widow PART CLAIMANT -1st below the name a Wrdow If none relationship ever is no survivrng wrdow are no children Is father d If there within of deceased 15A NEXT-OF-KIN appropriate No brothers lrst the survivrng the degrees check parent Is mother Indicated marriage or children* of chrldren If yes did list all the children child in a through terminate Include NAME OF EXECUTOR ADDRESS 1 158. THEDECEASED OR d orce decree II and III. cl Death Give Date by Divorce or illegitimate stating whrch class it or parents. c. list below the next of km who may be capable of inheriting from the deceased sisfers sisters etc*. Parts any adopted here AGE 15C. RELATIONSHIP VOTE - Complete Items 16 and 77 ONLY if any of the persons listed above 5 NAME AND ADDRESS OF GUARDIAN FOR ANY MINOR CHILDREN LISTED ABOVE IF ONE HAS COURT Attach copy or appOmme f paper issued by court Of Ihe p/aces below Check of are no survivors descendants address married list the descendants None was Insured IS and age copy DIVORCE II - 3. DATE OF DEATH DEATH JS or COMPLETING attach by V H RH RS W J JR and 2 SOCIAL SECURITY NUMBER FKS mrddle. /ast NSLI by K ADMINISTRATOR Ill IF ANY. 15D. ADDRESS are under age 21. BEEN APPOINTED BY THE THE BY THE COURT TO ESTATE SETTLE OF 19 IF AN EXECUTOR APPOINTED. WILL ONE HAS NOT 0 YES q N0 HEREBY CERTIFY that all statements f this clarm is suppressed or wrthheld. I request that the death benefit be paid III 36 Eaual Monthlv Any rntentronal false statement in thus claim or willful of not more than 5 years or both. 16 U*S*C. 1001. JULY 19 SEPTEMBER 2007 IV - misrepresentation EXISTING IF ADDITIONAL SPACE to a settlement In STOCKS relative IS REQUIRED thereto is subject to punrshment by a fine of not more JAN 1991 WILL BE USED. ATTACH SEPARATE SIGNED SHEETS* than 10 000 or BEEN THIS FORM SHOULD BE USED WHEN THE DECEASED HAD INSURANCE IN FORCE UNDER SERVICEMEN S GROUP LIFE INSURANCE INSURANCE VETERANS GROUP LIFE INSURANCE VGLI. SGLI OR VETERANS GROUP LIFE INSURANCE VGLI. PAYMENT BENEFITS Under Servicemen s l To the beneficiary the widow named child or children payable to a duly appointed Group in writing Life Insurance by the insured death benefit if none the insurance if none it is payable must be made in the following is payable order to in equal shares with the share of any deceased payments child distributed among of that child if none it is other next of kin* executor or administrator FOR DEATH of the insured s estate and if none to It is important that all requested information be furnished* Omission information should be typed or printed in ink except the signature.

Claim reimbursement form 1. DEPARTMENT OR ESTABLISHMENT, BUREAU, DIVISION OR OFFICE CLAIM FOR REIMBURSEMENT FOR EXPENDITURES ON OFFICIAL BUSINESS 3. SCHEDULE NUMBER Read the Privacy Act Statement on the back of this form.

Claims regarding conduct on or... 443 Lafayette Road N. St. Paul, Minnesota 55155 www.dli.mn.gov (651) 284-5005 1-800-DIAL-DLI TTY: (651) 297-4198 Claims Regarding Conduct On or After Dec. 1, 2007 TO: FROM: SUBJECT: Applicants to

Alaska quitclaim deed form Located within the IN WITNESS WHEREOF the Grantors have hereunto set their hands. Signature UNITED STATES OF AMERICA STATE OF ALASKA Judicial District SS The foregoing Quitclaim Deed was acknowledged before me by on this day of Signature of Notary My commission expires on Return Originals to Revised 10/04 Name Mailing Address. Electronic Form Instructions Mouse Click or Tab to the line and type in your infomation* Print the completed form before you close the file. Acrobat Reader will not save your input data* Sign and Mail the completed form and supporting documents to the regional office closest to you. MINING QUITCLAIM DEED THIS INDENTURE made and given this date of 20 by and between The Grantor name and address and WITNESSETH That the Grantor in consideration of quitclaim unto the Grantee the following Phone and other valuable considerations hereby convey and Claim s is/are situated in Name of Claim s ADL No* Meridian Township Range Section Recording District. Electronic Form Instructions Mouse Click or Tab to the line and type in your infomation* Print the completed form before you close the file. Acrobat Reader will not save your input data* Sign and Mail the completed form and supporting documents to the regional office closest to you. Acrobat Reader will not save your input data* Sign and Mail the completed form and supporting documents to the regional office closest to you. MINING QUITCLAIM DEED THIS INDENTURE made and given this date of 20 by and between The Grantor name and address and WITNESSETH That the Grantor in consideration of quitclaim unto the Grantee the following Phone and other valuable considerations hereby convey and Claim s is/are situated in Name of Claim s ADL No* Meridian Township Range Section Recording District. Electronic Form Instructions Mouse Click or Tab to the line and type in your infomation* Print the completed form before you close the file. Acrobat Reader will not save your input data* Sign and Mail the completed form and supporting documents to the regional office closest to you. MINING QUITCLAIM DEED THIS INDENTURE made and given this date of 20 by and between The Grantor name and address and WITNESSETH That the Grantor in consideration of quitclaim unto the Grantee the following Phone and other valuable considerations hereby convey and Claim s is/are situated in Name of Claim s ADL No* Meridian Township Range Section Recording District.

Shc107 form But agree with the rest. There is no paragraph 1 in Plaintiff s Complaint. ANSWER TO DIVORCE COMPLAINT Without Minor Children Page 1 of 7 SHC-107 09/11 whether I agree or disagree. You must use black ink to fill out this form* Your Name Mailing Address Message phone Telephone NOTE If for any reason you do not wish the other party to know your physical address you still must provide a mailing address so that the court and the other party can serve you by mail* IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT City or Town where the Court is located Plaintiff v* Defendant. Your Case No* ANSWER AND COUNTERCLAIM To Divorce Without Children I hereby submit my response to Print your name here plaintiff s complaint and allege as follows A. ANSWER Agree with the statements in paragraph 1 of the Complaint* Disagree with the statements in paragraph 1 of the Complaint* Do not understand the statements in paragraph 1 of the Complaint to decide whether I agree or disagree. B. AFFIRMATIVE DEFENSE S An affirmative defense is facts and arguments that attack the plaintiff s legal right to bring the court case. The affirmative defense might win for the defendant even if everything in the plaintiff s complaint is true. I have no affirmative defenses. Go to Section C. I further allege the following as my affirmative defense s I have never resided or been present in the State of Alaska* It is my position that the Alaska court does not have jurisdiction over any of the property or debt of the marital estate. I want the Alaska court to dismiss this case because I will be prejudiced if we are divorced before the property division occurs in another state. I have attached to this Answer a Motion to Dismiss. The venue of this action is improper. This case should have been filed at the courthouse in. City or Town Other C. COUNTERCLAIM S A counterclaim is where the defendant states what he/she wants to happen regarding the issues in the case. I have no counterclaims. Go to Section D. I have stated above that the Alaska court does not have jurisdiction over the dismiss the case I submit the following counterclaim s without waiving my claim about the court s lack of jurisdiction* Date of Separation I disagree with plaintiff s date of separation and assert that we have been continuously separated since Children We have NO minor children together and the wife is NOT pregnant. are children or paternity needs to be disestablished for any child ren born or conceived during the marriage this form will NOT work for you. Use Answer Counterclaim to Divorce With Minor Children SHC-105 Word PDF. Property 3A. There is no property or debt to be divided by this court and we can each keep what we have in our possession or control* 3B. marital property and debt be divided in a just and equitable manner. I am currently aware of the following types of property and debt Land Bank / credit union account s Building s include your home here 401 k / 403 b retirement account s Car / truck IRA account s Snow machine / 4-wheeler Pension Boat s Household goods Plane s Credit card debt s Gun s Debt related to property mortgages vehicle or equipment loans etc* Tools Other debt s Optional Comments 3C.

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