Professional legal forms

Standard insurance company bil... Reset Standard Insurance Company Billing Change Form 920 SW Sixth Avenue Portland OR 97204 Please refer to your Administration Guide for further instructions on completing this form. New employees and increases in coverage may be subject to eligibility/Evidence Of Insurability/Late Enrollment Penalty requirements. An enrollment form is required and should be kept on file by you for all contributory and life coverages. Group Name Policy/DIV No* Form Prepared by Phone No* email Date Prepared Employee Additions 1. Social Security Number Name Last First Middle Initial Birthday MM/DD/YYYY State of Employment Billing Category Earnings Hours per week if less than 40 Date of Full-time Employment Job Title/Occupation Male Week amount Month amount Female Hour amount Year amount Family Indicator Employee Employee Spouse Contributory Benefits No Yes Family Employee Children Note Some contributory benefits require Evidence Of Insurability or a Late Enrollment Penalty. Please consult your Group Policy or Administration Manual* If yes List FAX OPTION To ensure prompt processing of employee changes please FAX this form toll free to 1-800-378-2403 or you may mail this form to the address above or sign-up to update your membership data on-line with E-Billing Administration visit our demonstration site at www. standard. com/ebusiness. Changes shown here will be reflected on a subsequent billing statement. Please enter changes and terminations on side two. SI 7270 1 of 2 3/09 Please use this portion of the form for employee changes corrections or terminations and dependent changes corrections or deletions. New benefits and increases in coverage may be subject to eligibility/Evidence of Insurability/Late Enrollment Penalty requirements. Employee Changes or Corrections Employee Name Last First Middle Initial Effective Date of Change New Billing Category Coverage Type WK MO HR YR Employee Terminations Date of Termination Reason for Termination Comments Print 2 of 2. An enrollment form is required and should be kept on file by you for all contributory and life coverages. Group Name Policy/DIV No* Form Prepared by Phone No* email Date Prepared Employee Additions 1. Social Security Number Name Last First Middle Initial Birthday MM/DD/YYYY State of Employment Billing Category Earnings Hours per week if less than 40 Date of Full-time Employment Job Title/Occupation Male Week amount Month amount Female Hour amount Year amount Family Indicator Employee Employee Spouse Contributory Benefits No Yes Family Employee Children Note Some contributory benefits require Evidence Of Insurability or a Late Enrollment Penalty. Group Name Policy/DIV No* Form Prepared by Phone No* email Date Prepared Employee Additions 1. Social Security Number Name Last First Middle Initial Birthday MM/DD/YYYY State of Employment Billing Category Earnings Hours per week if less than 40 Date of Full-time Employment Job Title/Occupation Male Week amount Month amount Female Hour amount Year amount Family Indicator Employee Employee Spouse Contributory Benefits No Yes Family Employee Children Note Some contributory benefits require Evidence Of Insurability or a Late Enrollment Penalty. Please consult your Group Policy or Administration Manual* If yes List FAX OPTION To ensure prompt processing of employee changes please FAX this form toll free to 1-800-378-2403 or you may mail this form to the address above or sign-up to update your membership data on-line with E-Billing Administration visit our demonstration site at www.

The standard long term disabil... Reset State of Georgia - Long Term Disability Medical History Statement - Evidence of Insurability Form Standard Insurance Company Medical Underwriting 900 SW Fifth Avenue Portland OR 97204 DIRECTIONS FOR APPLYING FOR COVERAGE This form must be completed when Evidence Of Insurability is required. To apply for coverage read the Information Practices Notice s.

Standard bill of lading form II. The Standard Bill of Lading Form GS1 US VICS Standard BOL http //www. gs1us. org/ then click Logistics for complete BOL guideline information Date SHIP FROM Name Address City/State/Zip SID BILL OF LADING Bill of Lading Number Location CID FOB THIRD PARTY FREIGHT CHARGES BILL TO Freight Charge Terms freight charges are prepaid unless marked otherwise Prepaid Collect 3rd Party SPECIAL INSTRUCTIONS check box CUSTOMER ORDER NUMBER PKGS GRAND TOTALS HANDLING UNIT QTY TYPE PACKAGE WEIGHT PALLET/ SLIP Y N Master Bill of Lading with attached underlying Bills of Lading ADDITIONAL SHIPPER INFO CARRIER INFORMATION COMMODITY DESCRIPTION H. M. X Where the rate is dependent on value shippers are required to state specifically in writing the agreed or declared value of the property as follows The agreed or declared value of the property is specifically stated by the shipper to be not exceeding per. Commodities requiring special or additional care or attention in handling or stowing must be so marked and packaged as to ensure safe transportation with ordinary care. See Section 2 e of NMFC Item 360 LTL ONLY NMFC CLASS COD Amount Fee Terms Collect Prepaid Customer check acceptable NOTE Liability Limitation for loss or damage in this shipment may be applicable. See 49 U*S*C. 14706 c 1 A and B. RECEIVED subject to individually determined rates or contracts that have been agreed upon in writing between the carrier and shipper if applicable otherwise to the rates classifications and rules that have been established by the carrier and are available to the shipper on request. and to all applicable state and federal regulations. SHIPPER SIGNATURE / DATE This is to certify that the above named materials are properly classified packaged marked and labeled and are in proper condition for transportation according to the applicable regulations of the DOT. Trailer Loaded By Shipper Driver SUPPLEMENTAL BAR CODE AREA CARRIER NAME Trailer number Seal number s SCAC Pro number SHIP TO Page The carrier shall not make delivery of this shipment without payment of freight and all other lawful charges. Freight Counted CARRIER SIGNATURE / PICKUP DATE By Driver/pallets said to contain By Driver/Pieces Carrier acknowledges receipt of packages and required placards. Carrier certifies emergency response information was made available and/or carrier has the DOT emergency response guidebook or equivalent documentation in the vehicle. Property described above is received in good order except as noted* RECEIVING STAMP AREA SUPPLEMENT TO THE BILL OF LADING Page. PALLET/SLIP CIRCLE ONE PAGE SUBTOTAL and packaged as to ensure safe transportation with ordinary care. M. X Where the rate is dependent on value shippers are required to state specifically in writing the agreed or declared value of the property as follows The agreed or declared value of the property is specifically stated by the shipper to be not exceeding per. Commodities requiring special or additional care or attention in handling or stowing must be so marked and packaged as to ensure safe transportation with ordinary care.

Ohio department of insurance s... Insurance. ohio. gov Ohio Department of Insurance John R. Kasich Governor Mary Taylor Lt. Governor/Director Standardized Credentialing Form Part B Agency/Program/Organization Providers Please complete each section leaving no blank spaces. Product Regulation rd 50 W* Town St* 3 Fl Suite 300 Columbus OH 43215 614 644-2661 Fax 614 728-5238 www. Clearly state if information requested is not applicable or not available and why. Attach additional sheets when necessary. Separate forms may be required for each National Provider Identifier NPI practice location and provider type. You must include copies of the following documents as applicable with this completed application* Use this checklist as a guide State License Local Business License Registrations or Certifications DEA and/or CDS Certificate CLIA Certificate Terminal Distributor License Current Certificate of General Liability Insurance Form W-9 Workers Compensation Certificate of Coverage Accreditation Letter and Certificate Medicare Certification Letter If the Provider is not accredited please include the following information C. V. of Medical Director C. V. of Clinical Director Credentialing Plan Most recent CMS or State Surveys Correction Action Plans and Revisit Reports Documented staff attendance at OSHA Training Documented compliance with OSHA record keeping rules regarding workplace injuries and illness Confidentiality Plan NA Note Please submit this form directly to health plans and other entities that credential facility providers for participation in their networks. DO NOT send this form to the Ohio Department of Insurance the Department does not use the form for any reporting purposes. Accredited by the National Association of Insurance Commissioners NAIC INS5036 Rev* 01/2011 Page 1 of 8 Provider Identification Legal Name of Applicant Federal Tax Identification Number Doing Business As DBA Type of Provider NPI Primary Office Address Mailing Address if different from business address City State Zip Code Date and State of Incorporation or Registration List all other states in which applicant is approved to conduct external reviews Length of time in business with this legal name and Tax ID Year Applicant Opened Address If different from above Phone Fax Email Applicant Owner/Parent Company Type of Entity Corporation Partnership Check one Joint Venture Other List all memberships in professional organizations and trade associations Limited Liability Company Medical Director Name Last First Middle Degree Specialty Office Address Provider Practice Information Name Street Address/PO Box Website Primary Contact Name and Title Hours of Monday Operation Included in Provider Directory Yes No Federal Tax ID number Tuesday Wednesday Thursday Friday Saturday Sunday List language and sign language interpreters/ contractors Is teletype available Administrator/ Site Manager Service Areas Counties Handicapped Access On Bus Route Number of Beds Additional Practice Location Billing Information To whom shall checks be made payable Billing Address Street/PO Box Type of Claim Form Used CMS1500 UB04 UB92 Accrediting Agency Name Have you ever been denied accreditation by any accrediting body If yes please provide details Licensure and Certifications Medicaid Provider Number and Status License Number and Status CLIA Number Scope of Services List all services offered attach separate page if necessary Does the Provider have a toll free number Yes Is the Provider part of a national network of providers Yes If Yes please describe What is the accepted age range of the Provider s patients Liability Insurance General Liability Coverage Attach certificate showing current coverage amounts and effective dates Name of Carrier Policy Number Coverage Type Occurrence Based Claims Based Effective Date Expiration Date Per Incident Aggregate Professional Liability Malpractice Coverage Staffing Provide a list of the types numbers of professional disciplines licensures and/or certifications represented on the staff* Electronic Capabilities What are the Provider s current electronic capabilities What billing and documentation software is the Provider currently using What version is the software Sent in groups Batch Or one at a time Real Time What is the name of the EMR software Is the EMR software compatible with your billing and documentation software Disclosure Questions Please answer the following questions by checking the appropriate box.

Standard family law interrogat... INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE FORM 12.930(c), STANDARD FAMILY LAW INTERROGATORIES FOR MODIFICATION PROCEEDINGS (09/09) When should this form be used? This form should be used

Zimbabwe standard chartered re... REMITTANCE APPLICATION FORM Please fill in using BLOCK LETTERS Branch Applicant's Information (Sender) Name of Sender* Address Resident Transfer Instructions Payment Method Debit A/C No.* Charges

A method for estimating insect... A method for estimating insect abundance and patch occupancy with potential applications in large-scale monitoring programmes G. Sileshi* World Agroforestry Centre (ICRAF), SADC-ICRAF Agroforestry

Form adopted for mandatory use... Form Adopted for Mandatory Use Judicial Council of California FL-110 Rev. July 1 2009 Deputy Asistente Clerk by Secretario por as an individual. a usted como individuo. FL-110 CITACI N Derecho familiar SUMMONS Family Law FOR COURT USE ONLY NOTICE TO RESPONDENT Name AVISO AL DEMANDADO Nombre You are being sued. Lo est n demandando. S LO PARA USO DE LA CORTE To keep other people from seeing what you entered on your form please press the Clear This Form button at the end of the form when finished* Petitioner s name is Nombre del demandante CASE NUMBER N MERO DE CASO You have 30 calendar days after this Summons and Petition are served on you to file a Response form FL-120 or FL-123 at the court and have a copy served on the petitioner. A letter or phone call will not protect you. Tiene 30 d as corridos despu s de haber recibido la entrega legal de esta Citaci n y Petici n para presentar una Respuesta formulario FL-120 FL-123 ante la corte y efectuar la entrega legal de una copia al demandante. Una carta o llamada telef nica no basta para protegerlo. If you do not file your Response on time the court may make orders affecting your marriage or domestic partnership your property and custody of your children* You may be ordered to pay support and attorney fees and costs. If you cannot pay the filing fee ask the clerk for a fee waiver form* Si no presenta su Respuesta a tiempo la corte puede dar rdenes que afecten su matrimonio o pareja de hecho sus bienes y la custodia de sus hijos. La corte tambi n le puede ordenar que pague manutenci n y honorarios y costos legales. Si no puede pagar la cuota de presentaci n pida al secretario un formulario de exenci n de cuotas. If you want legal advice contact a lawyer immediately. You can get information about finding lawyers at the California Courts Online Self-Help Center www*courtinfo*ca*gov/selfhelp at the California Legal Services Web site www. lawhelpcalifornia*org or by contacting your local county bar association* Si desea obtener asesoramiento legal p ngase en contacto de inmediato con un abogado. Puede obtener informaci n para encontrar a un abogado en el Centro de Ayuda de las Cortes de California www. sucorte. ca*gov en el sitio Web de los Servicios Legales de California www. lawhelpcalifornia*org o poni ndose en contacto con el colegio de abogados de su condado. NOTICE The restraining orders on page 2 are effective against both spouses or domestic partners until the petition is dismissed a judgment is entered or the court makes further orders. These orders are enforceable anywhere in California by any law enforcement officer who has received or seen a copy of them* AVISO Las rdenes de restricci n que figuran en la p gina 2 valen para ambos c nyuges o pareja de hecho hasta que se despida la petici n se emita un fallo o la corte d otras rdenes. Cualquier autoridad de la ley que haya recibido o visto una copia de estas rdenes puede hacerlas acatar en cualquier lugar de California* NOTE If a judgment or support order is entered the court may order you to pay all or part of the fees and costs that the court waived for yourself or for the other party.

Superintendent letter ets ets... Educational Testing Service CAHSEE Support Center 2731 Systron Dr. Concord, CA 94815 800-241-5687 CAHSEE-Support ets.org FROM: DATE: TO: James Pisano Ph.D, ETS, Project Director June 8, 2011 Select

Fha clause form FHA DISCLOSURES AMENDATORY CLAUSE / REAL ESTATE CERTIFICATION Buyer(s) Seller(s) Property Address : Date of Agreement: File No.: FHA AMENDATORY CLAUSE It is expressly agreed that notwithstanding any

Settlement brief form Clear Print ATTORNEY OR PARTY WITHOUT ATTORNEY Name and Address TELEPHONE NO. FOR COURT USE ONLY ATTORNEY FOR Name SUPERIOR COURT OF CALIFORNIA COUNTY OF SAN BERNARDINO STREET ADDRESS MAILING ADDRESS CITY AND ZIP CODE BRANCH NAME PETITIONER/PLAINTIFF RESPONDENT/DEFENDANT CASE NUMBER MANDATORY SETTLEMENT CONFERENCE BRIEF Date of Hearing Time Dept/Rm Judge NOTE THE WORD HUSBAND MEANS FATHER AND THE WORD WIFE MEANS MOTHER IN CASES WHERE THE PARTIES ARE NOT MARRIED. I. STATISTICAL DATA A. Date of Marriage B. Date of Separation C. Date Jurisdiction Acquired D. Length of Marriage E* Marital Status Terminated F* Husband s Age Yes No If so date and Employment G* Husband s Net Monthly Income H. Wife s Age I. Wife s Net Monthly Income J* Minor Children NAME DATE OF BIRTH AGE SEX RESIDING WITH K. Child Care Costs Per Month -1ACIS Code 37154 01 13-18598-356 SB-598 II. INCOME AND EXPENSE California Rule 243 The latest Income and Expense Declaration form No* 1285. 50 filed by Husband is dated If a party s Income and Expense Declaration is over six months old or if there have been significant changes since the filing of the last Income and Expense Declaration a new declaration must be prepared and filed with this statement. III. The parties agree on the following issues Check applicable items. Custody of Children Visitation Rights Child Support or Spousal Support Restraining Orders Division of Property Division of Debts Other IV. EXISTING ORDERS Briefly summarize date and nature of each existing order concerning any issue that is not agreed to V. DISPUTED ISSUES AND HUSBAND S/WIFE S PROPOSALS RE ISSUES If more space is needed please attach additional sheet s of paper. VI. ATTACHMENTS AND EXHIBITS A. Where issues include division of assets counsel or party shall attach relevant schedules of proposed division* Or if property declaration Forms 1285. 56 have been filed attach copies. B. If a party requests reimbursements for community debts paid from separate funds Smith/Epstein attach a schedule and canceled checks receipts or other supporting materials. attach a schedule and canceled checks or receipts or other supporting materials. D. Other appropriate attachments may be included to set forth the contentions of a party to provide the relevant information and pro thereto and to promote settlement. VII. STIPULATIONS In the event a trial is required Husband/Wife will stipulate to the following facts or legal issues I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I. STATISTICAL DATA A. Date of Marriage B. Date of Separation C. Date Jurisdiction Acquired D. Length of Marriage E* Marital Status Terminated F* Husband s Age Yes No If so date and Employment G* Husband s Net Monthly Income H. Wife s Age I. Wife s Net Monthly Income J* Minor Children NAME DATE OF BIRTH AGE SEX RESIDING WITH K. Wife s Age I. Wife s Net Monthly Income J* Minor Children NAME DATE OF BIRTH AGE SEX RESIDING WITH K. Child Care Costs Per Month -1ACIS Code 37154 01 13-18598-356 SB-598 II. INCOME AND EXPENSE California Rule 243 The latest Income and Expense Declaration form No* 1285.

Biopreferred brand guidelines... www.biopreferred.gov United States Department of Agriculture Brand guidelines and graphic standards for the usda biopreferred program The Voluntary Labeling, Biobased Product Certification and Federal

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

Showing results for:

Get legally binding signatures now!