Purchase Information for Purchases Made Without Using Insurance Sample Clauses

Purchase Information for Purchases Made Without Using Insurance. Provide the number of boxes (of 30 patches each) that you purchased for your own use or for the use of your family members. FILL OUT THIS SECTION ONLY IF YOU MADE LIDODERM PURCHASES WITHOUT USING INSURANCE. Only include purchases 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 BOXES (OF 30 PATCHES EACH) NUMBER OF BOXES (OF 30 PATCHES EACH) Provide the number of brand Lidoderm boxes (of 30 patches each) you purchased from August 23, 2012 through September 14, 2013 in the above- listed states. By filling in any number in the box to the right, I hereby also certify that, if a generic version of Lidoderm was available at a cheaper price from August 23, 2012 to September 14, 2013, I would have purchased the generic version of Lidoderm. GENERIC LIDODERM (LIDOCAINE PATCH 5%) BOXES (OF 30 PATCHES EACH) NUMBER OF BOXES (OF 30 PATCHES EACH) Provide the number of generic Lidoderm (Lidocaine patch 5%) boxes (of 30 patches each) you purchased from September 15, 2013 through August 1, 2014 in the above-listed states.
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Related to Purchase Information for Purchases Made Without Using Insurance

  • How Do I Get More Information? For more information, including the full Notice, Claim Forms and Settlement Agreement go to xxx.xxxxxxxxxxxxxxxxxxxx.xxx, contact the settlement administrator at 0-000-000-0000, or call Class Counsel at 1-866-354-3015. Exhibit E UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF FLORIDA Xxxxx v. AvMed, Inc., Case No. 10-cv-24513 If You Paid for or Received Insurance from AvMed, Inc. at Any Time Through December of 2009, You May Be Part of a Class Action Settlement. IMPORTANT: PLEASE READ THIS NOTICE CAREFULLY. THIS NOTICE RELATES TO THE PENDENCY OF A CLASS ACTION LAWSUIT AND, IF YOU ARE A MEMBER OF THE SETTLEMENT CLASSES, CONTAINS IMPORTANT INFORMATION ABOUT YOUR RIGHTS TO MAKE A CLAIM UNDER THE SETTLEMENT OR TO OBJECT TO THE SETTLEMENT (A federal court authorized this notice. It is not a solicitation from a lawyer.) Your legal rights are affected whether or not you act. Please read this notice carefully. YOUR LEGAL RIGHTS AND OPTIONS IN THIS SETTLEMENT SUBMIT A CLAIM FORM This is the only way to receive a payment. EXCLUDE YOURSELF You will receive no benefits, but you will retain any rights you currently have to xxx the Defendant about the claims in this case. OBJECT Write to the Court explaining why you don’t like the Settlement. GO TO THE HEARING Ask to speak in Court about your opinion of the Settlement. DO NOTHING You won’t get a share of the Settlement benefits and will give up your rights to xxx the Defendant about the claims in this case. These rights and options – and the deadlines to exercise them – are explained in this Notice. QUESTIONS? CALL 0-000-000-0000 TOLL FREE, OR VISIT XXX.XXXXXXXXXXXXXXXXXXXX.XXX PARA UNA NOTIFICACIÓN EN ESPAÑOL, LLAMAR O VISITAR NUESTRO WEBSITE BASIC INFORMATION

  • Vendor Logo (Supplemental Vendor Information Only) No response Optional. If Vendor desires that their logo be displayed on their public TIPS profile for TIPS and TIPS Member viewing, Vendor may upload that logo at this location. These supplemental documents shall not be considered part of the TIPS Contract. Rather, they are Vendor Supplemental Information for marketing and informational purposes only. Bid Attributes Disadvantaged/Minority/Women Business & Federal HUBZone Some participating public entities are required to seek Disadvantaged/Minority/Women Business & Federal HUBZone ("D/M/WBE/Federal HUBZone") vendors. Does Vendor certify that their entity is a D/M/WBE/Federal HUBZone vendor? If you respond "Yes," you must upload current certification proof in the appropriate "Response Attachments" location. NO Historically Underutilized Business (HUB) Some participating public entities are required to seek Historically Underutilized Business (HUB) vendors as defined by the Texas Comptroller of Public Accounts Statewide HUB Program. Does Vendor certify that their entity is a HUB vendor? If you respond "Yes," you must upload current certification proof in the appropriate "Response Attachments" location. No National Coverage Can the Vendor provide its proposed goods and services to all 50 US States? Yes

  • Shipping must be Freight On Board Destination to the delivery location designated on the Customer purchase order The Contractor will retain title and control of all goods until delivery is completed and the Customer has accepted the delivery. All risk of transportation and all related charges are the responsibility of the Contractor. The Customer will notify the Contractor and H-GAC promptly of any damaged goods and will assist the Contractor in arranging for inspection. The Contractor must file all claims for visible or concealed damage. Unless otherwise stated in the Agreement, deliveries must consist only of new and unused merchandise.

  • What To Do If You Find A Mistake On Your Statement If you think there is an error on your statement, write to us at the address(es) listed on your statement. In your letter, give us the following information:

  • Sharing Information with Billers You authorize us to share identifying personal information about you (such as name, address, telephone number, Xxxxxx account number) with companies that you have identified as your Billers and which we have identified as offering electronic bills for purposes of matching your identity on the Service’s records and the Xxxxxx’x records to (a) activate your affirmative request for electronic bills, and/or (b) confirm your eligibility for “trial basis” electronic bills.

  • Internet Access to Contract and Pricing Information Access by Authorized Users to Contract terms and pricing information shall be made available and publically posted on the OGS website. To that end, OGS shall publically post the Contract Pricelist, including all subsequent changes in the Contract offerings (adds, deletes, price revisions), Contractor contact information, and the Contract terms and conditions, throughout the Contract term.

  • Modifications and Updates to the Wire Center List and Subsequent Transition Periods 2.1.4.12.1 In the event BellSouth identifies additional wire centers that meet the criteria set forth in Section 2.1.4.5, but that were not included in the Initial Wire Center List, BellSouth shall include such additional wire centers in a carrier notification letter (CNL). Each such list of additional wire centers shall be considered a “Subsequent Wire Center List”.

  • Background and Narrative of Budget Reductions 2. Assumptions Used in the Deficit Reduction Plan: - EBF and Estimated New Tier Funding: - Equal Assessed Valuation and Tax Rates: - Employee Salaries and Benefits: - Short and Long Term Borrowing: - Educational Impact: - Other Assumptions: - Has the district considered shared services or outsourcing (Ex: Transportation, Insurance) If yes please explain: ESTIMATED LIMITATION OF ADMINISTRATIVE COSTS (School Districts Only) (For Local Use Only)

  • DOES THE SPR NEED TO BE UPDATED IF INFORMATION CHANGES Yes. It remains a continuing obligation of the principal or his/her authorized agent to update the SPR whenever any of the information provided on the initial form changes. WHERE DO THE SPR AND ANY UPDATES NEED TO BE FILED? The SPR needs to be filed with the County Department or County Division processing the application or matter. If and when an additional expenditure is incurred subsequent to the initial filing of the SPR, an amended SPR needs to be filed with the County Department or County Division where the original application, including the initial SPR, was filed. WHEN DO THE SPR AND ANY UPDATES NEED TO BE FILED? In most cases, the initial SPR needs to be filed with the other application forms. The SPR and any update must be filed with the appropriate County Department or County Division not less than seven (7) days prior to the BCC hearing date so that they may be incorporated into the BCC agenda packet. (See Section 2-354(b), Orange County Code.) When the matter is a discussion agenda item or is the subject of a public hearing, and any additional expenditure occurs less than 7 days prior to BCC meeting date or updated information is not included in the BCC agenda packet, the principal or his/her authorized agent is obligated to verbally present the updated information to the BCC when the agenda item is heard or the public hearing is held. When the matter is a consent agenda item and an update has not been made at least 7 days prior to the BCC meeting or the update is not included in the BCC agenda packet, the item will be pulled from the consent agenda to be considered at a future meeting.

  • Changes to the Notice Information Either Party may change this information by giving five Business Days written notice prior to the effective date of the change.

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