Please complete. In the case of a work-related injury, the employee agrees to report the injury immediately to the UF Workers’ Compensation Office, (000) 000-0000, to get instructions for obtaining medical treatment and complete the required documentation. When the remote location is in the home, workers’ compensation does not cover injuries that are not job related. Employees who work out of state or out of the country in one location for more than 30 days need workers’ compensation coverage specific to that location.
Please complete. Thank you for providing your experience and skills in the CCCC online classroom. We look forward to working with you to expand opportunities for our students.
Please complete. My name is My Class I understand and agree to abide by the Safe and Responsible Behaviour Expectations.
Please complete. It is our hope to provide the highest quality of service. Below you will find a patient information sheet which provides our office with useful information that is helpful to our staff in contacting you, processing your billing and notifying you in case of an office closing, etc.
Please complete. Please describe the person(s) or program(s) that have provided care for your child until now.
Please complete. I would like to be kept informed of latest news and information from Catalina*.
Please complete. Federal Tax ID No.: ----------------------------------------- ----------------- (Agency Name) By: Date: ------------------------------------- ------------------------------- Title: ------------------------------------------ INSTRUCTIONS: This form should be sent to Donegal Group Inc., 1195 River Road, Marietta, Pennsylvaxxx 00000, Xxxxxxxxx: Xxxxx X. Xxxxxxx, Xxxxxr Vice Presidxxx, Xxxxx Xxxxxcial Officer and Secretary, along with a Subscription Agreement if not previously submitted for the Subscription Period and your check and be received prior to September 30 or March 31 of the respective Subscription Period or, in the case of the first Subscription Period, by October 31, 2001. The dollar amount set forth above must be at least $1,000 and may not exceed, when added to the amounts paid under the direct bill commission payment method and/ox xxe contingent commission payment method for the current Subscription Period, an aggregate of $12,000. September , 2001 ------ RE: IMPORTANT CHANGES TO THE DONEGAL AGENCY STOCK PURCHASE PLAN Dear Agent: Enclosed is a brochure highlighting the new Donegal Agency Stock Purchase Plan (the Plan), a Plan prospectus, latest Donegal Group Inc. Annual Report and Form 10-Q, and a Subscription Agreement form. Due to the recent recapitalization of Donegal Group Inc. that created two separate classes of common stock, the Company was required to adopt a new Agency Stock Purchase Plan. AS A RESULT, ALL PARTICIPANTS IN THE PREVIOUS PLAN MUST RE-ENROLL IN THE NEW PLAN IN ORDER TO CONTINUE TO PARTICIPATE IN A COMMISSION WITHHOLDING METHOD. Any funds remaining in your current account after the purchase of stock on September 30, 2001, will be returned to you. The first subscription period of the new Plan will commence on October 1, 2001 and end on March 31, 2002. If you elect to participate in this subscription period, please complete the enclosed Subscription Agreement form indicating your preference of payment method. If you select the lump sum payment method, the Subscription Agreement and payment may be submitted at any time prior to the end of the subscription period. If you select the direct bill or contingent commission method, xxe Subscription Agreement must be submitted to our office prior to November 1, 2001, in order for your agency to be enrolled in the first subscription period. Should any questions arise, please feel free to contact Dan Wagner or Jeff Miller at 1-888-800-0000. Sincerely, Ralph G. Spontak Senior Vice Preside...
Please complete. Federal Tax ID No.: -------------------------------------- ---------------- (Agency Name) By: Date: ----------------------------------- ------------------------------ Title: -----------------------------
Please complete. Undersigned’s Term Loan hold amount immediately prior to the Restatement Effective Date: $ __________ Very truly yours, _______________________________________, By: Name: Title:: By: * Name: Title:: * If a second signature is needed. Each Converting Lender (including the Fronting Banks with respect to Reallocated Term Loans, if any), shall be deemed to have a Restatement Effective Date Term Commitment in an aggregate principal amount equal to the outstanding principal amount of Existing Term Loans or Reallocated Term Loans of such Converting Lender that are exchanged for Restatement Effective Date Term Loans in accordance with this Agreement. Restatement Effective Date Revolving Commitments: * Confidential treatment has been requested with respect to all the redacted portions of the document, which has been filed separately with the Securities and Exchange Commission.
