Claim Forms. The Company, upon receipt of a notice of claim will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within fifteen (15) days after receipt of such notice the claimant shall be deemed to have complied with requirements of this Policy as to proof of loss upon submitting, within the time fixed in the Policy of filing proofs of loss, written proof covering the occurrence, the character and extent of the loss for which claim is made.
Claim Forms. The Company, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proof of loss. If such forms are not furnished within fifteen (15) days after the giving of such notice the claimant shall be deemed to have complied with the claim filing requirements of this Contract.
Claim Forms. HMO must require all THSteps providers to submit claims for services paid (either on a capitated or fee-for service basis) on the HCFA 1500 claim form and use the unique procedure coding required by TDH.
Claim Forms. Upon receipt of a notice of claim, we will furnish to the claimant such forms as are usually furnished by us for filing proofs of loss. If claim forms are not furnished within twenty (20) days after the giving of notice, the claimant shall be deemed to have complied with the requirements of this Agreement as to proof of loss upon submitting, within the time fixed in the contract for filing proof of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made. Please note that you are not required to use a claim form to notify us of a claim. When you receive an itemized bill from a hospital, physician, or ancillary provider not contracting with us, you may forward that bill directly to us for processing. Simply indicate the medical record number of the patient on the bill and submit it directly to us.
Claim Forms. A claim form can be requested by calling the Member and Provider Service telephone number on the identification card during regular business hours. CareFirst BlueChoice shall provide claim forms for filing proof of loss to each claimant. If CareFirst BlueChoice does not provide the claim forms within fifteen (15) days after notice of claim is received, the claimant is deemed to have complied with the requirements of the policy as to proof of loss if the claimant submits, within the time fixed in the policy for filing proof of loss, written proof of the occurrence, character, and extent of the loss for which the claim is made. When a child subject to a Medical Child Support Order or a Qualified Medical Support Order does not reside with the Subscriber, CareFirst BlueChoice will
Claim Forms. 8.1 The Beneficiary shall submit Claim Forms and supporting documents to the Authority in accordance with the instructions provided in the Guidance and on the Claim Form itself.
Claim Forms. (A) In order to receive a Settlement Award, Settlement Class Members must submit a valid Claim Form by the Claim Form Deadline via First Class United States Mail, postage prepaid.
Claim Forms. Each Settlement Class Member shall be entitled to submit one Combined Claim Form or one DSL Claim Form, for each account they had with Bumble, for Settlement Payment as described in this section.
Claim Forms. Allianz Life of NY will furnish Plan with a supply of claim forms initially, and upon request of the Plan.
Claim Forms. To make a claim under tier one in the Interstate Batteries Settlement Program, an eligible Settlement Class Member must complete and submit a timely, valid, signed (electronically or by hand), and certified tier-one claim form. The tier-one claim form will be substantially similar to Exhibit D. Tier-one claim forms can be completed and submitted online through the Class Settlement Website or mailed, by first-class U.S. Mail or overnight delivery, to Interstate Batteries’ Customer Service Department (the address for which will appear on the tier- one claim form). An eligible Settlement Class Member desiring to submit a tier-one claim form online must complete the online form, which will appear at xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx, and click the submission button at the bottom of that claim form no later than 11:59 p.m. Pacific Time on the Submission Deadline. An eligible Settlement Class Member may obtain a printed tier-one claim form either online at xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx, or by mail from Interstate Batteries’ Customer Service Department at an address that will appear on the Class Settlement Website. Tier- one claim forms submitted by either first class U.S. Mail or overnight delivery must be in an envelope that has a postmark or other postal service or professional courier marking that shows that the claim form was mailed or placed with a professional courier for overnight delivery on or before the Submission Deadline. To complete the tier-one claim form under the Interstate Batteries Settlement Program, a claimant must certify the following:
