Claim Form i. Within 15 days after receiving a notice of a claim, you or your Dental Provider will be provided with a Claim Form to make claim for Benefits. To make a claim, the form should be completed and signed by the Provider who performed the services, and by the patient (or the parent or guardian if the patient is a minor), and submitted to the address above.
Claim Form. Whenever an injury on the job is reported, a copy of this section shall be attached to the departmental form (currently the Supervisor’s Incident Investigation Report Form), and then provided to the employee. Employees are not required to sign or attest to the SIIR form (or its successor).
Claim Form. The Settlement Class Notice will include the Claim Form, in a form substantially similar to the one attached to the Settlement Agreement as Exhibit “B,” which will inform the Settlement Class Member that he/she must fully complete and timely return the Claim Form and supporting documents within the Claim Period to be eligible to obtain a recovery.
Claim Form. Vir meer inligting besoek: / For more information please visit: / Inkcukach ezithe vetshe uzakuzifumana aph: The Department of Trade and Industry: xxxx://xxx.xxxxxx.xxx.xx/ South African National Accreditation System: xxxx://xxx.xxxxx.xx.xx/directory.php Independent Regulatory Board of Auditors: xxxx://xxxx.xx.xx/index.php ………………………………………………………………………………………………………………………….. Besigheid of persoon se naam:- / Business or person's name:- / Igama leshishini okanye lomntu % **1. Persentasie aandeelhouding van persone (HBI) in die besigheid wat histories benadeel is as gevolg van onregverdige diskriminasie gebaseerd op ras. Percentage of shareholding of persons (HDI) in the business historically disadvantaged because of unfair discrimination based on race. Ipersenti yesabelo sabantu kwishishini elalisakuthinteleka ekuxhamleni amalungelo athile ngenxa yobandlululo ngokobuhlanga. %
Claim Form. Each Settlement Class Member shall be entitled to submit a Claim for Settlement Payment as described in this section.
Claim Form. “Claim Form” shall mean a form in substantially the same form as that attached hereto as Exhibit A.
Claim Form. The Long Form Notice shall describe the Claim Form and shall inform the Settlement Class Member: (i) the criteria to be used to determine whether the Settlement Class Member may select Tier 1, Tier 2, or Tier 3 payments; and (ii) that in order to claim any payment pursuant to the Settlement, the Settlement Class Member must fully complete and timely submit the Claim Form prior to the Claim Deadline.
Claim Form. The Class Notice shall include the Claim Form, which shall inform each Class Member that he or she must fully complete and timely return the Claim Form within the Claim Period to be eligible to obtain relief pursuant to this Agreement.
Claim Form. “Claim Form” means the proof of claim agreed to by the Parties and to be submitted for approval by the Court which shall be used by certain Class Members as described herein to file a claim under this Agreement. A copy of the Claim Form is attached hereto as Exhibit 1.
Claim Form. All claims must be submitted on a Claim Form. The Claim Form will require the Settlement Class Member to provide his or her full name, home mailing address, and telephone number; an affirmation that he/she has received services from Xxxxxxx House; and a signature affirming the accuracy of the included information.
