MEDICAL EXPENSE CERTIFICATE Sample Clauses

MEDICAL EXPENSE CERTIFICATE. TO BE COMPLETED BY INJURED PARTY OR, IF A MINOR, BY THE MINOR’S PARENT OR GUARDIAN NOTICE TO INJURED PARTY OR PARENT/GUARDIAN: This form must be submitted to the Member School District within one year of the occurrence that caused the accidental injury, with all required documentation and Attachment(s). Failure to provide complete information will affect recovery of benefits. Once you have fully completed the Medical Expense Certificate and attached all required documentation, sign this Medical Expense Certificate before a notary and submit it to the Superintendent or his or her designee, along with your completed Medical Expense Certificate Delivery Certification. The Superintendent or designee must complete page 7 and forward this form and all necessary documentation to the North Carolina School Boards Trust (“NCSBT”). See additional instructions on page 7. Accident/Injury Information
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MEDICAL EXPENSE CERTIFICATE. TO BE COMPLETED BY INJURED PARTY OR, IF A MINOR, BY THE MINOR’S PARENT OR GUARDIAN NOTICE TO INJURED PARTY OR PARENT/GUARDIAN: This form must be submitted to the Member School District within one year of the Occurrence, with all required documentation and Attachment(s). Failure to provide complete information will affect recovery of benefits. If the injured party does not have a Social Security Number or refuses to provide it, you MUST complete Attachment B. If the injured party’s Social Security number is provided, you do not need to complete Attachment B. Once you have fully completed the Medical Expense Certificate and attached all required documentation, sign this Medical Expense Certificate before a notary and return it to the Superintendent or his or her designee. The Superintendent or designee must complete page 6 and forward this form and all necessary documentation to the North Carolina School Boards Trust (“NCSBT”). See additional instructions on page 6. Accident/Injury Information
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Related to MEDICAL EXPENSE CERTIFICATE

  • Medical Expenses 1. Employees exposed to hazardous physical, biological, or chemical agents shall be provided, at no cost to the employee, with medical examinations or evaluations required by VOSHA regulations. If there are no specific VOSHA regulations or standards for the agent in question, recommendations of the National Institute of Occupational Safety and Health or other generally recognized expert organization shall be used, as determined by the Commissioner of Health.

  • Medical/Dental Expense Account The Employer agrees to allow insurance eligible employees to participate in a medical and dental expense reimbursement program to cover co- payments, deductibles and other medical and dental expenses or expenses for services not covered by health or dental insurance on a pre-tax basis as permitted by law or regulation, up to the maximum amount of salary reduction contributions allowed per calendar year under Section 125 of the Internal Revenue Code or other applicable federal law.

  • Child Care Expenses (a) Where an employee is requested or required by the Employer to attend:

  • REPORT ON CONTRACT SALES ACTIVITY AND ADMINISTRATIVE FEE PAYMENT A. CONTRACT SALES ACTIVITY REPORT. Each calendar quarter, Supplier must provide a contract sales activity report (Report) to the Sourcewell Supplier Development Administrator assigned to this Contract. Reports are due no later than 45 days after the end of each calendar quarter. A Report must be provided regardless of the number or amount of sales during that quarter (i.e., if there are no sales, Supplier must submit a report indicating no sales were made). The Report must contain the following fields: • Participating Entity Name (e.g., City of Staples Highway Department); • Participating Entity Physical Street Address; • Participating Entity City; • Participating Entity State/Province; • Participating Entity Zip/Postal Code; • Participating Entity Contact Name; • Participating Entity Contact Email Address; • Participating Entity Contact Telephone Number; • Sourcewell Assigned Entity/Participating Entity Number; • Item Purchased Description; • Item Purchased Price; • Sourcewell Administrative Fee Applied; and • Date Purchase was invoiced/sale was recognized as revenue by Supplier.

  • Unreimbursed medical expenses If you take payments to pay for unreimbursed medical expenses that exceed a specified percentage of your adjusted gross income, you will not be subject to the 10 percent early distribution penalty tax. For further detailed information and effective dates you may obtain IRS Publication 590-B, Distributions from Individual Retirement Arrangements (IRAs), from the IRS. The medical expenses may be for you, your spouse, or any dependent listed on your tax return. 5)

  • Covered Expenses Supervisors must have received prior authorization from their Appointing Authority before incurring any expenses authorized by this Article.

  • Insurance Certificate The contractor/renter provides the fair with a signed original certificate of insurance (the XXXXX form is acceptable), lawfully transacted, which sets forth the following:

  • Travel Expense Reimbursement Pricing for services provided under this Contract are exclusive of any travel expenses that may be incurred in the performance of those services. Travel expense reimbursement may include personal vehicle mileage or commercial coach transportation, hotel accommodations, parking and meals; provided, however, the amount of reimbursement by Customers shall not exceed the amounts authorized for state employees as adopted by each Customer; and provided, further, that all reimbursement rates shall not exceed the maximum rates established for state employees under the current State Travel Management Program (xxxx://xxx.xxxxxx.xxxxx.xx.xx/procurement/prog/stmp/). Travel time may not be included as part of the amounts payable by Customer for any services rendered under this Contract. The DIR administrative fee specified in Section 5 below is not applicable to travel expense reimbursement. Anticipated travel expenses must be pre-approved in writing by Customer.

  • Detailed Monthly Report Vendor shall electronically provide DIR with a detailed monthly report in the format required by DIR showing the dollar volume of any and all sales under the Contract for the previous calendar month period. Reports are due on the fifteenth (15th) calendar day of the month following the month of the sale. If the 15th calendar day falls on a weekend or state or federal holiday, the report shall be due on the next business day. The monthly report shall include, per transaction: the detailed sales for the period, Customer name, invoice date, invoice number, description, quantity, MSRP or List Price, unit price, extended price, Customer Purchase Order number, contact name, Customer’s complete billing address, the estimated administrative fee for the reporting period, subcontractor name, EPEAT designation (if applicable), configuration (if applicable), contract discount percentage, actual discount percentage, negotiated contract price (if fixed price is offered instead of discount off of MSRP), and other information as required by DIR. Each report must contain all information listed above per transaction or the report will be rejected and returned to the Vendor for correction in accordance with this section. Vendor shall report in a manner required by DIR which is subject to change dependent upon DIR’s business needs. Failure to do so may result in contract termination.

  • Payment of Extraordinary Education Related Expenses Section 5.1. PAYMENT OF EXTRAORDINARY EDUCATION-RELATED EXPENSES. In addition to the amounts determined pursuant to Articles IV and VI of this Agreement, Applicant on an annual basis shall also indemnify and reimburse District for all non-reimbursed costs, certified by the District’s external auditor to have been incurred by the District for extraordinary education-related expenses directly and solely related to the project that are not directly funded in state aid formulas, including expenses for the purchase of portable classrooms and the hiring of additional personnel to accommodate a temporary increase in student enrollment caused directly by such project. Applicant shall have the right to contest the findings of the District’s external auditor pursuant to Section 4.9 above.

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