Professional legal forms

Sample homeowners insurance po... (06 97). QUIT CK REFERENCE'SEE AL FORM. HOMEOWNERS SPEC AL FORM. MARYLAND SPEC ILL FIVE S I Wins. ADJUSTED BUI LYING COST ...

Icici prudential life insuranc... ICICI Prudential Life Insurance Policy Surrender Form Select Download Format:Download ICICI Prudential Life Insurance Policy Surrender Form decisions PDF. Download ICICI Prudential Life Insurance Policy Surrender Form doc.

Agreement to furnish insurance... Q TO REORDER CALL JB GRAPHICS (818) 90207672748911AGREEMENT TO FURNISH INSURANCE POLICY (TO BE USED WITH SECURITY AGREEMENT ON SALE OF VEHICLE)Date Seller undersigned Purchaser(s) agree(s) to furnish

Insurance policy form POLICY CHANGE REQUEST FORM Please mail completed form to Policy Processing P. O. Box 9026 Melville NY 11747 or Fax to 1 866 344-1295 AutoOne Insurance Company Effective Date of Change Policy Number Insured Name / Producer Name Street Address Insured Phone Producer Phone SS or Tax ID City/State/Zip NAME/ADDRESS CHANGE Name Correction Change New Name Address Mailing Garage Location ADD/REPLACE/DELETE VEHICLE Vehicle Deleted or Replaced Year Added Use Pleasure Farm Business Commute Anti-Theft Device Model Make Make Model VIN Miles to Work/School/Transportation Cost New Passive Active Name of Owner/Lessor if not named Principal Operator State of Registration Territory Rate Class Symbol Address on registration if other Was a Temporary ID Card issued Yes COVERAGES No Same Limits of Liability Apply to All Vehicles on Policy Add Bodily Injury Liability Delete Property Damage Applies to Personal Injury Protection Coverages Mandatory Full Limits/ Deductible Additional Guest Medical Payments Uninsured Motorists Statutory Supplementary UM SUM Comp. Other than Collision OBEL Annual Premium Authorization for Inspection Form must be attached. ADDITIONAL INSUREDS/LESSORS/LOSS PAYEES Additional Insured Loss Payee T31 500 03/03 DRIVER INFORMATION Add Driver Delete Driver REASON for deletion Relationship to Insured DOB Sex Marital Status Driver s License and State Licensed of use Veh. 1 Veh. 2 ACCIDENTS Additional driver s involved in any motor vehicle accident during the preceding 40 months Accident Date Accident Location PIP Claim Yes Bodily Injury or Death Property Damage Amount including your own Chargeable Please provide reasons if accident is not chargeable in Additional Comments section* CONVICTIONS Date of Type of Violation Conviction Place of Conviction ATTACHMENTS Check all that apply Certificate of Completion of Defensive Driver Course Certificate for Driver Training Credit Proof for Deleted Driver POLICY CANCELLATION Request to Cancel Entire Policy If FS-6 submitted to the company within 30 days of surrender of plates the effective date will be the day after the date of surrender of the plates. Otherwise effective date will be the company s date of receipt of the FS-6. ADDITIONAL COMMENTS Any person who knowingly makes or knowingly assists abets solicits or conspires with another to make a false report of the theft destruction damage or conversion of any motor vehicle to a law enforcement agency the department of motor vehicles or an insurance company commits a fraudulent insurance act which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation* Authorized Representative s Signature Insured s Signature if applicable. 1 Veh. 2 ACCIDENTS Additional driver s involved in any motor vehicle accident during the preceding 40 months Accident Date Accident Location PIP Claim Yes Bodily Injury or Death Property Damage Amount including your own Chargeable Please provide reasons if accident is not chargeable in Additional Comments section* CONVICTIONS Date of Type of Violation Conviction Place of Conviction ATTACHMENTS Check all that apply Certificate of Completion of Defensive Driver Course Certificate for Driver Training Credit Proof for Deleted Driver POLICY CANCELLATION Request to Cancel Entire Policy If FS-6 submitted to the company within 30 days of surrender of plates the effective date will be the day after the date of surrender of the plates. Otherwise effective date will be the company s date of receipt of the FS-6. ADDITIONAL COMMENTS Any person who knowingly makes or knowingly assists abets solicits or conspires with another to make a false report of the theft destruction damage or conversion of any motor vehicle to a law enforcement agency the department of motor vehicles or an insurance company commits a fraudulent insurance act which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation* Authorized Representative s Signature Insured s Signature if applicable.

Insurance policy record templa... Name Year Service Provided Date of Service Provider Medicare/Medical Insurance Record Tracking Form Medicare Private Insurance Patient Responsibility Assign Applied Amount Amount Amount Amount Amount Date -ed To Paid Patient Paid Billed Approved Sent Y or N Deductible Provider Patient Provider Patient Paid Check.

Collateral assignment of life... Collateral Assignment of Life Insurance Policy A. FOR VALUE RECEIVED, I (we) assign, transfer and set over to the Assignee, Name: Address: Date of Birth TIN No. Telephone Number of its successors

Adamjee insurance policy downl... ADAMJEE INSURANCE COMPANY LIMITED HEALTH INSURANCE DEPARTMENT 2nd Floor Adamjee Insurance Building Opp National Bank of Pakistan I. I. Chundrigar Road. Karachi-74000 Telephone 021 32414028 32420740 Fax 021 32470111 health adamjeeinsurance. com Health Questionnaire Form HQF Note This questionnaire is to be filled by the employee only. Any alteration must be signed by the employee. ADAMJEE INSURANCE COMPANY LIMITED HEALTH INSURANCE DEPARTMENT 2nd Floor Adamjee Insurance Building Opp National Bank of Pakistan I. I. Chundrigar Road* Karachi-74000 Telephone 021 32414028 32420740 Fax 021 32470111 health adamjeeinsurance. com Health Questionnaire Form HQF Note This questionnaire is to be filled by the employee only. Any alteration must be signed by the employee. Name of Employee In Block Letters Employer s Name Employee s NIC No Employee Code No if any Designation Joining Date Residential Address Phone No* FAMILY MEMBERS TO BE COVERED Please use additional sheet if necessary. S/ No* Name Relationship Date of Birth Height Feet Weight Ibs SELF Please read the following questions carefully and answer each question by ticking the appropriate boxes. If the answer to any of the question s is YES than please give full details disclosing the exact diagnosis attach copies of reports / investigations. If you are in any doubt than refer to your physician for the details. Non disclosure of any fact may invalidate a future claim* Before applying for insurance have you or any of your family members spouse/children/parents a* b. c* d. e. Aware/suffered from any medical condition/disease/illness/injury If yes details Received any diagnosis from a Doctor / Hakeem or Homeopath even if no treatment is provided Have any of the members listed above is suffering / suffered from any physical deformity Yes No Do you or any member of your family smoke or consume alcohol If yes than how much Are you or your spouse pregnant If yes how many months Are you and all members of your family listed above in good health PLEASE GIVE DETAIL S OF THE QUESTION S 1 a to 1 e TICKED YES. Name of the person whose answer has been ticked Yes Nature of Illness Medicines Taken Name of the Hospital Attended Physician Present Status DECLARATION AUTHORIZATOIN I hereby declare that what has been stated above is true and complete and to the best of my Please mention the plan / category for this employee. knowledge and belief* I have not withheld any material information and that it is understood and agreed that this declaration the application of my employer to the Adamjee Insurance Company Limited are the basis for the Group Hospitalization Insurance cover applied for and that any non-disclosure or misrepresentation of facts will make my/our insurance cover void since inception* I hereby authorize any hospital physician or surgeon who has or may attended to me or my family to furnish to the Adamjee Insurance Company Limited with any information they may require concerning my/our medical history or examinations.

Insurance policy card form Insurance Policy Card Homeowners Insurance Provider: Phone #: Policy #: Agent: Deductible: Policy Notes:Auto Insurance Provider: Phone #: Policy #: Agent: Deductible: Policy Notes:Life Insurance Provider: Phone

Electronic equipment insurance... The New India Assurance Company Limited Registered & Head Office : New India Assurance, 87, M.G. Road, Fort, Mumbai 400 001. QUESTIONNAIRE AND PROPOSAL FOR ELECTRONIC EQUIPMENT INSURANCE POLICY Downloaded

United india insurance policy... UNITED INDIA INSURANCE COMPANY LIMITED Reg. & Head Office: 24, Whites Road, Chennai — 14. BRANCH / DIVISIONAL OFFICE................... CLAIM FORM FOR HEALTH INSURANCE POLICY 2010 Policy No. Claim

Car insurance policy format no... UNITED INDIA INSURANCE CO LTD LIABILITY ONLY POLICY (For Private Cars / Two Wheelers)STANDARD PROPOSAL FORM FORA. Questions that are necessarily to be listed for granting the cover as per the Motor

Life insurance policy document... METROPOLITAN LIFE INSURANCE COMPANY NEW YORK, NEW YORKCERTIFICATE OF INSURANCE Metropolitan Life Insurance Company (MetLife), a stock company, certifies that You and Your Dependents are insured for

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