Professional legal forms

Guardiananytime form Dental Claim Form HEADER INFORMATION 1. Type of Transaction (Mark all applicable boxes) Statement of Actual Services EPSDT/ Title XIX 2. Predetermination / Preauthorization Number Request for Predetermination

Manulife affinity markets exte... Please complete page 2. The Manufacturers Life Insurance Company Page 1 of 2 AF1039E 01/2011 5 Equipment and appliance For equipment and appliance expenses Manulife Financial requires a written recommendation from the prescribing physician including diagnosis and a copy of the provincial plan statement of payment if applicable.

Manulife claim form gl3803blh Demande de remboursement sp cial pour m dicament sur ordonnance Assurance collective RENSEIGNEMENTS SUR LE PATIENT Nom du participant Nom du patient Ville Province Adresse Code postal N de t l phone

Mutual of omaha claim status d... LIFE INSURANCE CLAIM STATEMENT FOR BENEFICIARIES Please return with the Insured's certified death certificate. The furnishing of this form is not to be construed as an admission of the validity of

Sunlife claim forms Extended Health Care Claim Form sethisformforallmedicalexpensesandservices. U Fordentalexpenses,pleaseusetheDental Claim Form. leaseprintclearlyandbesureallsectionsarecompletetoavoid P delaysinprocessingyourclaim.

Aarp claim form life New York Life retains the right to make such determination. AARP has extensive grief and loss information and resources designed to assist family and friends during this difficult time. This information can be found online at www. griefandloss. org. NDCF2011v01a HOW TO COMPLETE YOUR CLAIM FORM Please read this page before you start to complete your Claim Form To complete the processing of your claim we must have a fully completed Claim Form from each beneficiary one certified death certificate and other documents as appropriate for the claim. SECTION 1 Information about the deceased is necessary for purpose of identification and benefit determination. Please be sure to enter the insurance contract number on the Claim Form. claims processing. Taxpayer Identification Number Life insurance benefits are generally not subject to income tax. Dear Beneficiary Please accept our condolences on your recent loss. We understand this is a difficult time and we hope that we can alleviate any concerns you may have about your claim* To help process your claim in the fastest possible manner New York Life Insurance Company is providing this easy to use Claim Form for your convenience. Please review the form in its entirety and then follow the step-by-step instructions to submit your claim* New York Life Insurance Company prides itself on the speed with which it pays claims. Most claim payments are sent to the beneficiaries within ten business days from the date the Company receives the completed Claim Form death certificate and other documents as appropriate to the claim* The claim form allows beneficiaries receiving 5 000 or more to elect to receive their proceeds in the form of a Continued Interest Account in addition to the option of receiving a lump sum payment by check. The Continued Interest Account is an interest bearing account that enables you to leave funds on deposit while you make important decisions during a difficult time. It provides immediate access to all of the proceeds at any time simply by writing a check for the full amount. Please see the enclosed page entitled Important Information About The Continued Interest Account which describes this option in greater detail* Please be assured that New York Life will act as quickly as possible to complete the processing of your claim once we receive all the necessary information and documentation* If you have any questions please contact us at 1-800-695-5165 between the hours of 8 am to 5 pm Monday through Friday. Sincerely Matt Pittarelli Corporate Vice President was in force at the time of death and the beneficiary to whom the proceeds may be payable. New York Life retains the right to make such determination* AARP has extensive grief and loss information and resources designed to assist family and friends during this difficult time. This information can be found online at www. griefandloss. org. NDCF2011v01a HOW TO COMPLETE YOUR CLAIM FORM Please read this page before you start to complete your Claim Form To complete the processing of your claim we must have a fully completed Claim Form from each beneficiary one certified death certificate and other documents as appropriate for the claim* SECTION 1 Information about the deceased is necessary for purpose of identification and benefit determination* Please be sure to enter the insurance contract number on the Claim Form* claims processing* Taxpayer Identification Number Life insurance benefits are generally not subject to income tax.

Air canada claims form Air Canada Baggage Claims Air Canada ZIP 1116 P. O. Box 8000 station Airport Dorval Quebec H4Y 1C3 Your claim must be made in writing within 21 days of your arrival. This completed and signed Interim Expense Form is the official written notice of a claim. The report made at the airport is an incident report only. INTERIM EXPENSES Please complete this form if your baggage was delayed and returned to you and you are now claiming for expenses incurred while your bag was not in your possession* If you live in North America the completed form should be mailed to our Montreal office at the address below. Residents of other countries should send it to the closest Air Canada office. PLEASE INCLUDE ALL AIRLINE TICKETS BAGGAGE CLAIM CHECKS AND EXCESS BAGGAGE RECEIPTS if applicable. PURCHASE RECEIPTS FOR ALL ITEMS CLAIMED MUST BE ATTACHED TO SUBSTANTIATE YOUR CLAIM. PLEASE ATTACH A PHOTOCOPY OF A SIGNED PHOTO IDENTIFICATION* If you have homeowner/household baggage or credit card insurance against which you may claim please complete question 10 below. All claims will be processed as quickly as possible. The Conditions of Contract on your ticket/e-ticket itinerary refer to limitations of liability based on tariffs and/or the Warsaw Convention and/or the Montreal Convention* These amounts are not automatically payable but reflect what the maximum compensation might be as each claim is subject to proof of loss. Please note that special rules apply to fragile and perishable items and that consequential damages such as loss of enjoyment loss of business inconvenience etc* are not compensable. Please also note that for domestic travel within Canada or for any travel where none of the aforementioned Conventions apply airlines are not liable for the loss of money jewelry silverware samples business documents electronic equipment or other valuable articles under any circumstance. Thank you for your cooperation and understanding. Baggage Tracing Number ex. YULAC12345 I Mr. / Mrs. / Ms. Family Name/s Given Name/s Name as indicated on Passport if different from above do solemnly declare that on the day of year I checked baggage belonging to expense claim is made. COMPLETE ITINERARY From To Airline Flight Number Full Date 1. Number of persons travelling together Infants under 2 years Ticket numbers 2. Total number of bags checked 3. Claim check or tag numbers 4. Were you charged for Additional Checked Bagage Amount paid Attach receipt 5. Did you declare excess valuation and purchase additional coverage Value declared Amount paid Attach receipt 6. Was there a name address or any other identification on the bag s i*e* tags stickers ribbons 7. Was the loss reported Time Date By phone or in person To which airline Where If the missing baggage was not reported immediately upon arrival state the reason for the delay Are you pursuing this claim with another carrier Carrier 8. Was your baggage rerouted or rechecked en-route Where Why By which airline New tag numbers 9. Was the baggage for which this claim is being made cleared through Customs If so where Were the contents inspected After clearance where was the baggage placed By whom 10.

Ontario deed form Transfer/Deed of Land. Form 1 - Land Registration Reform Act. R Province of. Ontario. Dvllb. A. ) ' f. f w (1) Registry E Land Titles 1 I (2) Page 1 of pages.

Carefirst state of maryland cl... Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Authorization is hereby given to any hospital physician or other provider which participated in any way in my care and treatment to release to CareFirst BlueCross BlueShield any...

Colonial life claim form This includes Employer and Attending Physician portions of the claim form. Signed by Print name Telephone Number Title Date Email Address Colonial Life products are underwritten by Colonial Life Accident Insurance Company for which Colonial Life is the marketing brand. However you may follow your Please check the activities of daily living that the patient is unable to perform Date s of office visit Last 3 Months How often do you see the patient Have you referred patient for other types of consultations Name and address of Specialist Dates of Hospitalization Last 3 months claim form. Signature of Physician Physician s Specialty Fax Number Tax ID or SSN Physician/Group Name Patient Account Number Do you accept Medical Records request by Fax Do you have authorization on file to release information to Colonial Life Was patient referred to you by another physician Provide the following information for referring doctor. Fax to Claims 1. 866. 887. 6644 From Number of pages Continuing Disability Claim Form Mail to P. O. BOX 100195 Columbia SC 29210 Questions Call 1. 800. 325. 4368 24 Hours A Day / 7 Days a Week Fax this direction* Do Not Use this Form if this is the first time you are filing for this injury or sickness If your name has changed please attach a copy of legal documentation i*e* marriage certificate or driver s license Section 1 TO BE COMPLETED BY POLICY OWNER Claimant name Mailing Address Male Female Birth Date Claimant Social Security Number Street or PO Box City State Apartment/Unit/Lot Number Zip Home telephone Policy owner e-mail address Work telephone Claim is for Accident Sickness Condition that keeps you from working Date the accident occurred not when it was treated Description of accident Were you at work at the time of your accident or sickness Yes No Dates unable to work To MM/DD/YYYY Have you been unable to perform any activities of daily living Yes No If yes please list the dates you were unable to perform the activities From To Check the activities that you are unable to perform dressing eating meal preparation toileting continence bathing transferring If not employed list dates of house confinement Date you returned to work House Confinement means you are kept at home by your condition* At Home means in your house or yard. However you may follow your doctor s orders even if it means leaving home. Full-time Part-time/Hours worked per week Dates employee unable to work Full-time Was employee at work when the accident or sickness occurred Date returned to work Employee job title Expected return to work Who should we contact for updates on return to work status Name/Phone/Email FRAUD NOTICE Any person who knowingly files a statement of claim containing false or misleading information is subject to criminal and civil penalties. 10/12-Visit us online at Coloniallife. com 46988-20 Claim Fraud Statements For your protection the laws of several states including Alaska Arkansas Delaware Idaho Indiana Louisiana Minnesota New Hampshire Ohio Oklahoma and others require the following statement to appear on this claim form* Fraud Warning Any person who knowingly and with intent to injure defraud or deceive an insurance company files a statement of claim containing any false incomplete or misleading information is guilty of insurance fraud which is a felony.

Mvp claim adjustment request f... CLAIM ADJUSTMENT REQUEST FORM Please attach a copy of this completed form when returning claims to MVP Health Care for adjustments. Check the box that best describes the purpose for submitting the Claim Adjustment Request Form and attachments. If you have questions on completing this form please call Provider Claims Services at 800 684-9286. West Region Rochester and Buffalo should call Provider Services at 585 325-3114 or 800 999-3920 THIS FORM IS NOT REQUIRED FOR THE FOLLOWING APPEALS No Authorization / Pre-Certification obtained PRIOR to service Medical Necessity Inpatient Hospital Mailing addresses for Appeals are at www. mvphealthcare. com on the Contacting MVP resource Today s Date Please submit one claim per adjustment form and do not highlight any fields on this form or any attachments. An asterisk denotes required information* Document claim Member ID Date of Service Provider Name Member Name Contact Name Provider ID Tax ID Contact Phone Coordination of Benefits Information Contact Fax 1. Alternate Insurance Information/EOB Coverage Attached 2. No-Fault /Workers Comp Information/EOB Attached 3. COB Related Adjustment 7. Transportation Run Record Requested Documentation Enclosed 1. Surgical or Surgical Modifier 4. Path/Rad Findings 8. Manufacturer s Invoice 2. Office Notes 5. Code Review/Asst. Surg* 9. Medical Record Review 3. Surgical/Operative Reports 6. Follow-up Days 10. Evidence of Qualifying Stay 11. Second Level Clinical Review Check Reason for Adjustment Request please check only one Options 1-8 require a corrected UB-92 or CMS-1500 to be attached showing all charges 1. Added/Deleted Charges 8. Copay/Deductible/Coinsurance Adjustment 9. Timely Filing Issue 3. Diagnosis Correction 10. Duplicate Denial Error 4. CPT/Modifier Correction 11. Implant/High Cost Drug Invoice Attached 5. ICD-9 Procedure UB92-Box 80 Correction 12. Provider Information Correction 6. Place of Service Correction 13. Referral or Pre-Auth Now on file- 7. Quantity Correction Please note reason for adjustment untimely filing or rationale for modifier use Please return this completed form and any supporting documentation to MVP Health Care P. Check the box that best describes the purpose for submitting the Claim Adjustment Request Form and attachments. If you have questions on completing this form please call Provider Claims Services at 800 684-9286. If you have questions on completing this form please call Provider Claims Services at 800 684-9286. West Region Rochester and Buffalo should call Provider Services at 585 325-3114 or 800 999-3920 THIS FORM IS NOT REQUIRED FOR THE FOLLOWING APPEALS No Authorization / Pre-Certification obtained PRIOR to service Medical Necessity Inpatient Hospital Mailing addresses for Appeals are at www. West Region Rochester and Buffalo should call Provider Services at 585 325-3114 or 800 999-3920 THIS FORM IS NOT REQUIRED FOR THE FOLLOWING APPEALS No Authorization / Pre-Certification obtained PRIOR to service Medical Necessity Inpatient Hospital Mailing addresses for Appeals are at www. mvphealthcare. com on the Contacting MVP resource Today s Date Please submit one claim per adjustment form and do not highlight any fields on this form or any attachments.

Seven corners form INJURY AND ILLNESS PROOF OF LOSS FORM Seven Corners Inc. 303 Congressional Blvd. Carmel IN 46032 USA Phone 800 335-0477 or 317 575-2656 Fax 317-575-2256 800-335-0477 or 317-575-2656 Fax 317-575-2256 Print this Form scanned documents are accepted via e-mail to claims sevencorners. I agree that I will provide Seven Corners Inc. with any medical records or other records requested by Seven Corners Inc. to process the claim. I understand that my failure to provide requested documents to Seven Corners Inc. may result in denial of the claim. I understand that failure by any of the above referenced entities or individuals to provide information or documents to Seven Corners Inc. may result in denial of the claim. In addition I hereby certify that the above information is true and correct to the best of my knowledge and belief. I understand that any false statements made on this form or omissions of information requested by this form may result in denial of the claim. I acknowledge and understand the Fraud Notices on Page 3 of this document. Signature of Insured Optional for Insured s Convenience I further agree to allow Seven Corners to send copies of explanation of benefit forms copies of claim correspondence and other confidential medical. Pennsylvania Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or Tennessee Virginia Washington It is a crime to knowingly provide false incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment fines and denial of insurance benefits. Texas Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Claim Correspondence/Payment Instructions primary information Insured ID Patient correspondence information Yes No Yes Phone in the US Phone Outside of the US Address in the US address city state postal code Address Outside the US address city state postal code country payment information Payments to be sent to Bank account in the US No If yes provide Banking Information in section below bank information Bank s name Bank s Address address city state postal code country Bank s Phone Bank s Account Type of account Name on Account exactly as it appears on your bank statements IBAN Number and/or Swift Code required for wire transfers Bank currency for this account Bank routing/sort code Checks cannot be sent to Banks outside the United States Wire transfer for Banks outside the United States only Greater than 50. 00 USD Disclaimer II hereby authorize and request Seven Corners to mail any correspondence and/or payments to the above listed address. Penalties include imprisonment fines and denial of insurance benefits. Texas Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Claim Correspondence/Payment Instructions primary information Insured ID Patient correspondence information Yes No Yes Phone in the US Phone Outside of the US Address in the US address city state postal code Address Outside the US address city state postal code country payment information Payments to be sent to Bank account in the US No If yes provide Banking Information in section below bank information Bank s name Bank s Address address city state postal code country Bank s Phone Bank s Account Type of account Name on Account exactly as it appears on your bank statements IBAN Number and/or Swift Code required for wire transfers Bank currency for this account Bank routing/sort code Checks cannot be sent to Banks outside the United States Wire transfer for Banks outside the United States only Greater than 50. 00 USD Disclaimer II hereby authorize and request Seven Corners to mail any correspondence and/or payments to the above listed address. II further agree to release Seven Corners of any and liability in the the eventlostloststolen correspondence/payments. Penalties. coverage information Insurance Carrier Name of Group / Plan Coverage Effective Date month/day/year Coverage Termination Date month/day/year // Policy / Certificate Number insured information Name of Insured last first middle initial suffix claimant information Name of Claimant last first middle initial suffix Date of Birth month/day/year Sex M F current address Current Residence Address address city state postal code country permanent address Daytime Phone Number area and / or country code If Applicable Date scheduled to return to Home Country Email Address or N/A medical information If Injury provide details i.e. how when and where injury occurred If Illness advise when and where symptoms first occurred and nature of illness Name and address of Consulting or Treating Physicians Have you ever been treated for this Illness before Yes No If Yes when Provide Name and Address of your Primary Care Physician in your Home Country Indicate other Employer / Private / Government Medical Insurance coverage include name address policy number and certificate number of Insurer Please advise names of any prescription medications you are presently taking I the undersigned authorize any hospital or other medical-care institution physician or other medical professional pharmacy insurance support organization governmental agency group policyholder insurance company association employer relative or benefit plan administrator to furnish to Seven Corners Inc. any and all information with respect to any injury or illness suffered by the medical history of or any consultation prescription or treatment provided to the person whose death injury illness or loss is the basis of the claim and copies of all that person s hospital or medical records including information relating to mental illness and use of drugs and alcohol to determine eligibility for benefit payments under the policy identified above.

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