AMOUNT CLAIMED. Please type or print in the box below, the total amount paid or reimbursed by you—net of co-pays, deductibles, and co-insurance— for purchases of brand Lidoderm between August 23, 2012, and September 14, 2013, and/or generic versions of Lidoderm (Lidocaine patch 5%) between September 15, 2013, and August 1, 2014, by your insureds, plan participants, or beneficiaries or their family members in Arizona, California, Florida, Kansas, Maine, Massachusetts, Minnesota, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, South Dakota, Tennessee, West Virginia, or Wisconsin. BRAND LIDODERM OR GENERIC LIDODERM (LIDOCAINE PATCH 5%) TOTAL AMOUNT PAID Purchases or Reimbursements from August 23, 2012 thru September 14, 2013 in the above-listed states. $ GENERIC LIDODERM (LIDOCAINE PATCH 5%) TOTAL AMOUNT PAID Purchases or Reimbursements from September 15, 2013 thru August 1, 2014 in the above-listed states. $ You must submit claims data and information (documentation) in support of the purchase amounts stated above if the total net claim amount is more than $10,000. That claims documentation must include the following fields: Client FEIN, Carrier ID, Account ID, Group ID, Member ID, Date of Service, NDC, Drug Name, Product Description, Quantity, Total Paid, Member Paid, Plan Paid, Pharmacy Name and Pharmacy Location. If your total net claim is $10,000 or less, you need not provide complete claims data with this Claim Form, but the Claims Administrator may require supporting documentation.
AMOUNT CLAIMED. “Amount Claimed” shall have the meaning set forth in Section 5.9.
AMOUNT CLAIMED. 15. If you were unable to work because of illness, how many days were you off work?
AMOUNT CLAIMED. Unspecified Brief Description: Plaintiffs filed an amended complaint (the "Amended Complaint") on April 16, 2008 to name Covenant Transportation Group, Inc. ("CTG") and Covenant Transport Solutions, Inc. ("Solutions") as defendants in a lawsuit previously filed by BNSF on December 21, 2007 against nine former employees of BNSF (the "Individuals") who, after leaving BNSF, accepted employment with Solutions. The original complaint alleged that the Individuals misappropriated and otherwise misused BNSF's trade secrets, proprietary information, and confidential information (the "BNSF Information") with the purpose of unlawfully competing with BNSF in the transportation logistics and brokerage business, and that the Individuals interfered unlawfully with BNSF's customer relationships. In addition to the allegations from the original complaint, the Amended Complaint alleges that CTG and Solutions acted in conspiracy with the Individuals to misappropriate the BNSF Information and to use it unlawfully to compete with BNSF. The Amended Complaint also alleges that CTG and Solutions interfered with the business relationship that existed between BNSF and the Individuals and between BNSF and its customers. BNSF seeks injunctive relief, specific performance, and an unspecified amount of damages. On April 28, 2008, an Answer to the Amended Complaint was filed. A jury trial in this matter has been set for November 3, 2008. An estimate of the possible loss, if any, or the range of the loss cannot be made at this time. COVENANT TRANSPORT, INC. Name of Plaintiff(s): HXXXXX, XXXX X., next of kin of HXXXXX, XXXXXXX XXXXX, deceased, Plaintiff Court: Chancery Court, Hxxxxxxx County, TN Case Number: 07-0701
AMOUNT CLAIMED. Unspecified Brief Description: Plaintiff filed suit on August 10, 2007 for workers' compensation benefits under the Tennessee Workers' Compensation Act alleging that on or about June 28, 2006, the decedent sustained a compensable injury that resulted in the decedent's death during the scope of the decedent's employment with Covenant Transport, Inc. Plaintiff requests that the court determine the nature and extent of the decedent's disability and award compensation and such other benefits as are provided by law. COVENANT TRANSPORT, INC. Name of Plaintiff(s): WXXXXXXX, XXXX, widow and dependant of WXXXXXXX, XXXXX, deceased Court: Chancery Court, Hxxxxxxx County, TN Case Number: 07-0968 Amount Claimed: Unspecified Brief Description: Plaintiff filed suit on November 7, 2007 for workers' compensation benefits under the Tennessee Workers' Compensation Act (the "TWCA") alleging that on or about November 2, 2006, the decedent sustained an injury, which resulted in the decedent's death during the scope of the decedent's employment with Covenant Transport, Inc. Plaintiff requests the court award the maximum death benefits and the bad faith penalty provided for under the TWCA and other relief available under the law. COVENANT TRANSPORT, INC. Name of Plaintiff(s): ROCK LOGISTICS, INC. Court: US District Court – Eastern District of Tennessee, Chattanooga Division, TN Case Number: 1:08-cv-00148 Amount Claimed: $6,000,000 Brief Description: Plaintiff filed a complaint on June 3, 2008, in Chancery Court, Hxxxxxxx County, TN for damages that allegedly occurred on or about November 14, 2007, in connection with a certain shipment. Plaintiff alleges that the defendant violated various provisions of the Tennessee Consumer Protection Act. Plaintiff is suing the defendant for $3,000,000 compensatory damages plus $3,000,000 punitive damages, plus attorney's fees. Case transferred to US District Court-Eastern District of Tennessee, Chattanooga Division, TN June 25, 2008. COVENANT TRANSPORT, INC. Name of Plaintiff(s): DXXXXXXXX, XXXXXX Court: US District Court – Eastern District Court of Tennessee, Chattanooga Division, TN Case Number: 1:07:07-CV-00265 Amount Claimed: $750,000.00 Brief Description: Plaintiff filed a complaint in the Chancery Court of Hxxxxxxx County, Tennessee, on September 28, 2007. Defendant filed a Notice of Removal on October 30, 2007. Plaintiff states she filed suit to secure protection and redress for an alleged deprivation of rights granted by the Tennessee ...
