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.
ii. If a Claim Form is not sent to you or your Provider within 15 days after you or your Provider gave notice regarding a claim, the requirements for proof of loss outlined in the section “Written Notice of Claim/Proof of Loss” above will be deemed to have been complied with as long as you give written proof that explains the type and the extent of the loss that you are making a claim for, within the time established for filing proofs of loss. You may also download a Claim Form from the dental plan website at xxx.xxxxxxxxxxxxxx.xxx.
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. Vir meer inligting besoek: / For more information please visit: / Inkcukach ezithe vetshe uzakuzifumana aph: Besigheid of persoon se naam:- / Business or person's name:- / Igama leshishini okanye lomntu
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. “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. Each Claim Form will be assigned a unique identifier that can be used by Participating Settlement Class Members to track their Claims. The Claim Form will contain various anti-fraud provisions used for validation, verification, and allocation of the Settlement benefits subject to review by the Parties. Such anti-fraud provisions shall not be so onerous as to discourage participation by Settlement Class Members.
Claim Form. To obtain monetary relief as part of the Settlement, a Class Member must fill out and submit a Claim Form, either by completing one online or by hard copy and mailing it to the Class Administrator. The Claim Form will ask the Claimant to provide customary identifying information, including his or her name, mailing address, email address, and telephone number. The Claim Form will also ask the Claimant to confirm, under penalty of perjury, that he or she purchased one or more of the Class Products and to state the number of Class Products he or she purchased. The Claim Form will also give the Claimant the option to provide Proof of Purchase for his or her purchase(s) of the Class products, or Proof of Purchase of Potentially Affected Products, if available. A maximum of one (1) Claim Form may be submitted per household.
