Professional legal forms

Ireland health insurance appli... Apply for ERIC How to apply for your European Health Insurance Card 1. Apply online if you already have either a medical card or a Drugs Payment Scheme (DPS) card 2. Apply in person by completing

Individual life insurance appl... Individual Life Insurance Application for Reinstatement with Evidence of Insurability Interstate Compact states Good Order Checklist: Use this checklist to make sure you have provided all the information

Long term care liability insur... TDC Specialty Insurance Company (hereafter, the Underwriter) A wholly owned subsidiary of The Doctors Company Servicing Address: 1888 Century Park East, Suite 850 Los Angeles, CA 90067Procedure Questionnaire THIS

Health insurance application f... Generali Worldwide Health Plan Medical Questionnaire Gastrointestinal Please complete all sections in BLOCK CAPITALS or tick the boxes, where appropriate.Group Number: Employer Name: Employee Name:Employee

Globe life insurance applicati... Application for Reinstatement United Home Life Insurance Company ? 225 S. East St. ? P.O. Box 7192 ? Indianapolis, IN 46207-7192 ? 1-800-428-3001 Policy Number Proposed Insured Premium Collected Spouse

Marine insurance application f... Motor ID Year Value Dinghy ID Year Value Dinghy Motor ID Year Value Not covered unless itemized Total Hull and Machinery Value Premium Additional Personal Effects/Fishing Equipment Attach List Value Premium Trailer ID Year Value Premium Optional Coverages Premium Loss Payable Name Liability 300 000 Included City State Zip Liability 1 million Policy Fee 55 Hull Deductible Total Premium List all Operators of the Vessel List all auto moving traffic violations and at fault accidents per operator Name date of birth years experience use drivers license In the past 3 years date of accident date of conviction description of incident license revoked 1 Where is Boat Moored Where Laid up Ashore Afloat Is Boat Transported Over Land Yes No How far How often Type of Vessel Sailboat Trawler Cruiser High Performance Houseboat Runabout Other Does Yacht have Sleeping Quarters Galley Head Radar Compass Depth Finder SS Radio Propane Live Aboard Yes No Loran GPS Head Autopilot Vapor Detection System Built in CO2 or Halon System Fire Extinguishers Is Yacht of Fiberglass Construction Yes No Specify Fuel Type Gas Diesel Max Speed Of Engines Manufacturer Inboard Outboard I/O Jet Total HP Any Chartered Use Yes No Navigation Limits Requested Insurance ever Refused or Cancelled No Yes Reason Please Read Before Signing Application This application will be incorporated in its entirety into any relevant policy of insurance where Insurers have relied upon the information contained herein. Any misrepresentations or concealment in this application for insurance will render insurance coverage null and void from inception. Please therefore check to make sure that all questions have been fully answered and that all facts material to your insurance have been disclosed if necessary by a supplement to the application. A consumer report containing personal credit factual or investigative information about the applicant may be sought in connection with this application for insurance or any renewal extension or variation thereof. Signing this form does not bind the Applicant to purchase the insurance or the Insurer to accept the risk but it is agreed that this form shall be the basis of the contract should a policy be issued. Signature of Applicant Signature of Agent Date ALT Insurance Group Lafleurinsurance aol.com 253-536-2403 Agent s Firm Agent Return Fax Return E mail NOTE INSURANCE IS NOT IN EFFECT UNTIL PREMIER HAS ISSUED A BINDER NUMBER Binders expire 15 days from the effective date unless payment is received by Premier Marine within the binder period. 800 FIFTH AVENUE SUITE 4100 SEATTLE WASHINGTON 98104 TOLL FREE LINE 1 800 589 4208 FAX 1 800 522 4461. PREMIER MARINE INSURANCE Application for Insurance Ocean Marine Insurance Quote Only Please Bind Insured Phone Wk Hm Address City State Zip Date of Birth Occupation Employer No. of Years as owner of a boat No. of Years as Operator/Crew Insurance Effective Date Previous Insurer This or prior boats Policy Exp Date Size and Type of Previous Boats Member of Cruising Club Date of Marine Survey Boating Education and Courses Boating Losses in last 3 years claimed or not date description Coverages Hull Machinery Make Model Year Serial Registration Length Date Purchase Replacement Current Purchased Price Cost New Market Value Outboard or Aux. Motor ID Year Value Dinghy ID Year Value Dinghy Motor ID Year Value Not covered unless itemized Total Hull and Machinery Value Premium Additional Personal Effects/Fishing Equipment Attach List Value Premium Trailer ID Year Value Premium Optional Coverages Premium Loss Payable Name Liability 300 000 Included City State Zip Liability 1 million Policy Fee 55 Hull Deductible Total Premium List all Operators of the Vessel List all auto moving traffic violations and at fault accidents per operator Name date of birth years experience use drivers license In the past 3 years date of accident date of conviction description of incident license revoked 1 Where is Boat Moored Where Laid up Ashore Afloat Is Boat Transported Over Land Yes No How far How often Type of Vessel Sailboat Trawler Cruiser High Performance Houseboat Runabout Other Does Yacht have Sleeping Quarters Galley Head Radar Compass Depth Finder SS Radio Propane Live Aboard Yes No Loran GPS Head Autopilot Vapor Detection System Built in CO2 or Halon System Fire Extinguishers Is Yacht of Fiberglass Construction Yes No Specify Fuel Type Gas Diesel Max Speed Of Engines Manufacturer Inboard Outboard I/O Jet Total HP Any Chartered Use Yes No Navigation Limits Requested Insurance ever Refused or Cancelled No Yes Reason Please Read Before Signing Application This application will be incorporated in its entirety into any relevant policy of insurance where Insurers have relied upon the information contained herein. Any misrepresentations or concealment in this application for insurance will render insurance coverage null and void from inception. Please therefore check to make sure that all questions have been fully answered and that all facts material to your insurance have been disclosed if necessary by a supplement to the application. A consumer report containing personal credit factual or investigative information about the applicant may be sought in connection with this application for insurance or any renewal extension or variation thereof. Signing this form does not bind the Applicant to purchase the insurance or the Insurer to accept the risk but it is agreed that this form shall be the basis of the contract should a policy be issued. Signature of Applicant Signature of Agent Date ALT Insurance Group Lafleurinsurance aol.com 253-536-2403 Agent s Firm Agent Return Fax Return E mail NOTE INSURANCE IS NOT IN EFFECT UNTIL PREMIER HAS ISSUED A BINDER NUMBER Binders expire 15 days from the effective date unless payment is received by Premier Marine within the binder period.

Allstate insurance application... M. to 8 00 P. M. Eastern Standard Time. The furnishing of this form or its acceptance by the Company as proof must not be construed as an admission of any liability on the part of the Company nor a waiver of any of the conditions of the insurance contract. POLICYHOLDER / CERTIFICATEHOLDER Insured s Name Patient Policy Number s 1 Male Female Insured s Social Security Number Patient s Date of Birth / MO/DAY/YR Home Number E-mail Filing a claim for ...

Allstate insurance application... M. to 8 00 P. M. Eastern Standard Time. The furnishing of this form or its acceptance by the Company as proof must not be construed as an admission of any liability on the part of the Company nor a waiver of any of the conditions of the insurance contract. POLICYHOLDER / CERTIFICATEHOLDER Insured s Name Patient Policy Number s 1 Social Security Number Date of Birth / Male Female MO/DAY/YR Home Number E-mail Filing a claim for your calendar year W...

Home insurance application for... RESET FIELDS Please fill in Completely. HOMEOWNERS/DWELLING FIRE/CONDO APPLICATION (3/09) Quote Number Check One POLICY PERIOD HOA HOB HO1 HO2 HO4 HO6 HO8 DP-1 TO Same Date 12 months PRIMARY SECONDARY

Gsis fire insurance applicatio... PROPERTY APPLICATION FORM Name of Assured: Date: Address: GOVERNMENT SERVICE INSURANCE SYSTEM Financial Center, Rojas Blvd., Pasty City Attention: The Manager Marketing Department Insurance Group

Property insurance application... B- 061-44 (Revised 8/76) F1-1 PROPERTY INSURANCE APPLICATION Address:. Date: GOVERNMENT SERVICE INSURANCE SYSTEM Manila GENTLEMEN: Attention: General Insurance Department In accordance with Section

Online insurance application f... Human Resources and Skills Development Canada Ressources humaines et D veloppement des comp tences Canada APPLICATION FOR EMPLOYMENT INSURANCE PREMIUM REDUCTION - For assistance see the guide called The Employment Insurance Premium Reduction Program which is available online at www. servicecanada.gc.ca/prp. - You must complete an application form for each payroll account for which you require a premium reduction. - You must include a copy of each short-term disability plan you want to register. Human Resources and Skills Development Canada Ressources humaines et D veloppement des comp tences Canada APPLICATION FOR EMPLOYMENT INSURANCE PREMIUM REDUCTION - For assistance see the guide called The Employment Insurance Premium Reduction Program which is available online at www. servicecanada*gc*ca/prp* - You must complete an application form for each payroll account for which you require a premium reduction* - You must include a copy of each short-term disability plan you want to register. For details see page 5 in the guide. R Payroll account P Company name Mailing address City Prov* Postal code 1. Specify how many employees reported under the payroll account indicated above are covered by your short-term disability plan s. 2. If you have employees indicated in question 1 for whom you remit Quebec Parental Insurance Plan premiums indicate the number. Returning the employees portion of the savings See page 6 in the guide. 3. Five-twelfths 5/12 of the savings from the premium reduction belongs to the employees to whom the reduced rate applies. As the employer you are required to return this amount to the employees. How will you return this portion of the savings By signing this application I declare that the employees portion as indicated above - is at least equal to 5/12 of the savings - is a new benefit or an enhancement to an existing employee benefit - is accessible to all employees to whom the reduced rate applies and - will be provided in the year for which the reduction is given or within the first four months of the following year. Note If you and your employees have signed a mutual agreement on how you will return their part of the savings 5/12 or if the details of the method used are contained in a collective agreement please include a copy of the relevant document with this application* I declare that the information provided on this form is true and accurate to the best of my knowledge. Title Name of authorized contact please print - Fax Signature Tel* Please return this form along with any other required documents to You may call us at 1-800-561-7923 EI Premium Reduction Program PO Box 11000 Bathurst NB E2A 4T5 For office use only HRSDC NAS5022 2010-03-002 E Date Fax 506-548-7473 File Request date Disponible en fran ais NAS 5022F Date sent. servicecanada*gc*ca/prp* - You must complete an application form for each payroll account for which you require a premium reduction* - You must include a copy of each short-term disability plan you want to register. For details see page 5 in the guide. R Payroll account P Company name Mailing address City Prov* Postal code 1.

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