Claim Information definition

Claim Information means data submitted via First Report of Injury (FROI) or Subsequent Report of Injury (SROI).

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Claim Information has the meaning set forth in Section 6.3.

Claim Information means a Claim Request and/or any associated Claim Response.

Examples of Claim Information in a sentence

• An Enrolled Claimant who fails to timely produce the Additional Claim Information may appeal to a Special Master who, for good cause, may afford the Enrolled Claimant additional time.

• Enhancements may be available as set forth in the EBP Award Schedule to a Qualified Claimant who claims such Enhancements and whose EBP Claim Form, Claim Package, EBP Claim Package and Additional Claim Information, if any, demonstrate entitlement.

• Each capitalized term listed below is defined in the corresponding Section of this Agreement: Additional Claim Information.

• The failure to provide such notice or the Claim Information therein, however, shall not release the Indemnifying Party from any of its obligations under this ARTICLE VIII except to the extent that the Indemnifying Party is prejudiced by such failure.

• Within 14 days of the Effective Date, the National Settlement Administrator shall mail a National Compensation Program Claim Form, together with instructions, a Base Point Category and Adjustment Calculation Worksheet, a set of Frequently Asked Questions, and a W-9 Form to the Tort Trust Beneficiaries identified by the Tort Trustee who filed, or who had filed on their behalf, a timely Proof of Claim or Personal Injury and Wrongful Death Claim Information Form (“PITWD Addendum”) in the Chapter 11 Case.

More Definitions of Claim Information

Claim Information means information about all of the following:

Claim Information means any legal advice, information, communications and documents disclosed to, provided to, generated by or exchanged between the parties to the Scheme and/or the Lawyers in relation to the Action.

Claim Information means: (1) a short form Preliminary Fact Sheet (“PFS”) and associated documents2; OR (2) a Fleet Phospho-Soda Litigation Summary Information Sheet (“LSIS”) and associated documents3; OR (3) the client’s medical records related to the alleged OSPS injury4; OR

Claim Information. Diagnosis: Date of Onset: Prognosis: Claimant injured? Yes No Date of Injury: Place Injury Occurred: How did the injury occur? Subrogation applicable? Case Management? Yes Yes No If “Yes”, please provide details: No Vendor Name and Phone: Claims Paid to Date: $ Claims Pending: $ Total Eligible Benefits this Submission: Less Specific Deductible: Balance: Less Previous Claim Submission: Reimbursement Amount Requested (this claim): Simultaneous Funding Amount being Requested: $ [$ ] $ [$ ] $ Yes No $ ▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇.▇▇▇ I certify that:

Claim Information. Diagnosis: Date of Onset: Prognosis: Claimant injured? Yes No Date of Injury: Place Injury Occurred: How did the injury occur? Subrogation applicable? Case Management? Yes Yes No If “Yes”, please provide details: No Vendor Name and Phone: Claims Paid to Date: $ Claims Pending: $ Total Eligible Benefits this Submission: Less Specific Deductible: Balance: Less Previous Claim Submission: Reimbursement Amount Requested (this claim): Simultaneous Funding Amount being Requested: $ [$ ] $ [$ ] $ Yes No $ ▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇.▇▇▇ I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ATTACHED FRAUD NOTICE, THAT THE ABOVE INFORMATION IS CORRECT AND THAT THE CLAIMS HAVE BEEN PAID IN ACCORDANCE WITH THE PLAN DOCUMENT. Authorized Signature: Printed Name: Title: Company Name: Date: E-mail: Phone: Relation to Policyholder: Mailing Address: Proof of Eligibility Enrollment Form (initial/current) Copy of Hour Bank/Dollar Bank Proof of Premium Payments COBRA Election form and Proof of payments Court Orders Election Form/Medicare Card Coordination of Benefits/Other Insurance Deductible/Coinsurance – Proof of satisfaction Complete Paid Claims Detail/History Report Facility Universal Bill/DRG Code Itemized Bills/Electronic Claim Data R&C Calculations for Out of Network Claims Copy of Contracted/Case rates Proof of Pre-certification/Approval Hospital Audits/Reviews findings Hospital Records/Medical Reports Large Case Management Reports Proofs of Payment Cumulative paid claims report Investigative materials to support claim: • Subrogation information • Work Comp information • Accident Details (police report, etc.) ▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇.▇▇▇

Claim Information has the meaning set out in Schedule 4.2.

Claim Information has the meaning set forth in Section 9.3.