Medical Insurance Information Sample Clauses

Medical Insurance Information. If you have no insurance, you must contact our office to assist you in getting medical coverage for the duration of the program. Students must have insurance in order to participate in NAPCA programs.
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Medical Insurance Information. This camper is covered by family medical/hospital insurance. ❑ Yes ❑ No Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable. Insurance company Policy number Subscriber _ Insurance company phone number ( )
Sample 1
Medical Insurance Information. The Brandywine Classic will provide a certified athletic trainer on-site to respond to anyone in need of medical attention. Accordingly, I hereby authorize the Brandywine Classic directors to act for me according to their best judgment in case of any situation requiring medical attention. I understand that every participating student is required to have health insurance coverage that provides an appropriate level of benefits befitting a participant in a contact sport including lacrosse. Participating students cannot be registered without providing the following complete health insurance information as follows: Medical Insurance Carrier:
Sample 1
Medical Insurance Information. Please complete the following information pertaining to the individual whose name appears on the insurance card AND provide a copy of the FRONT and BACK of the INSURANCE CARD. Adult Carrying Insurance: Relationship to Cadet: Adult’s Date of Birth: / / Adult’s Social Security # Adult’s Employer: Employer's Telephone #: ( ) - _ Employer's Address: Name of Insurance Company: Telephone #: ( ) - _ Address: City: State: Zip code: Policy #: Certificate #: Group #: CANDIDATE SIGNATURE DATE PARENT/GUARDIAN SIGNATURE DATE PARENT/GUARDIAN SIGNATURE DATE HAWAII NATIONAL GUARD YOUTH CHALLENGE ACADEMY CUSTODY INFORMATION CADET LAST NAME: CADET FIRST NAME: CADET DATE OF BIRTH: / / CADET SOCIAL SECURITY NUMBER: CADET IDENTIFYING MARKS (Scars, Birthmarks, Tattoos, etc.): Primary Nationality Gender Height Weight Hair Color Eye Color CUSTODIAL PARENT(S)/GUARDIAN (S)*: HOME ADDRESS: CITY: STATE: ZIP: HOME PHONE: BUSINESS PHONE: SECOND PARENT(S)/GUARDIAN(S)*: HOME ADDRESS: CITY: STATE: ZIP: HOME PHONE: BUSINESS PHONE: SECONDARY CONTACT: HOME ADDRESS: CITY: STATE: ZIP: HOME PHONE: BUSINESS PHONE: RELATION TO CADET: If you complete the 2nd Parent information, please xxxx yes or no to the following questions.
Sample 1
Medical Insurance Information. Medical Insurer: Policy Number: Primary Doctor’s Name: Phone #: Hospital Information Name: Address: Phone #: Parent/Guardian Signature Date CONSENT TO PHOTOGRAPH, FILM, OR AN INDIVIDUAL FOR NON-PROFIT USE I hereby provide consent to the Seattle Indian Health Board (SIHB), its representatives, employees, and its affiliated program partners, to participate in interviews, provide quotes, and/or use my image in photographs or videos for educational, public service, or health awareness purposes. I also grant them the right to edit, use, and xxxxx said products for non-profit purposes, including use in print, on the internet, and in all other forms of media. I also hereby release the SIHB and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above. I have read and understand the above: Parent/Guardian Signature Date (If under 18) Youth Participant Signature Date EMERGENCY CONTACT INFORMATION In case of an emergency, please list whom we need to contact in order of priority. Parent/Guardian: Relationship to youth: Home Phone: Work/Message Phone: Second to Contact: Relationship to youth: Home Phone: Work/Message Phone: I understand that the information given on this form will be used to contact members and relatives for emergencies only. TRANSPORTATION Seattle Indian Health Board is providing transportation from our location (000 00xx Xxx X.) to Taholah, Washington. Pick up: Sunday July 14th at 12 pm Returning to Seattle: Thursday July 18th at 5:30 pm Will one of the above contacts be responsible for transporting the youth participant to the designated drop-off and pick-up location at Seattle Indian Health Board? Yes, please specify who: If NO, please provide contact information: Name: Relationship to youth: Home Phone: Work/Message phone: Parent/Guardian Signature Date 2019 GONA PACKING LIST Please keep this list for your reference Overnights will be spent at an open space in the Taholah Community Center.  1 Pair - comfortable, sturdy walking shoes with good tread  1 Pair - sandals or flip flops  5 Pair - socks  5 Pair - underwear  5 Pair - shorts or pants  5 Shirts (T-shirts)  1 Backpack
Sample 1

Related to Medical Insurance Information

  • Medical Insurance Upon termination of employment, the Executive shall be entitled to all COBRA continuation benefits available under the Company's group health plans to similarly situated employees. To the extent permitted under Code Section 409A, during the applicable Payout Period, the Company shall provide such COBRA continuation benefits to the Executive at the active employee rates similarly situated employees must pay for such benefits. Upon the expiration of such Payout Period, the Executive will be responsible for paying the full COBRA premiums for the remaining COBRA continuation period.

  • Insurance Information The Borrower shall deliver to the Administrative Agent information concerning insurance at the times and in the manner specified in Section 7.8;

  • Basic Medical Insurance All regular Employees may choose to be covered by the medical plan for which the British Columbia Medical Plan is the licensed carrier. Benefits and premiums shall be in accordance with the existing policy of the plan. The Employer will pay one hundred percent (100%) of the regular premium.

  • Optical Insurance The Employer shall contribute the full composite premium cost for an optical insurance plan policy premium for each SUCCESS employee deemed eligible (e.g. Vision Service Plan). Participation in the optical insurance benefit is voluntary for each eligible SUCCESS employee. In order to qualify for the Employer’s share of the monthly premium, the SUCCESS employee must qualify under the rules and regulations of the respective carrier and may enroll in one of the following plans:

  • Retiree Medical Insurance Retiree insurance coverage is included within each medical plan for all retirees under the age of 65 years, through self-payment. The Employer shall make available an appropriate medical plan for all eligible retirees ages 65 years or older.

  • TOOL INSURANCE 278. The City agrees to indemnify employees covered under this Agreement for the loss or destruction of the employee's tools subject to the following conditions:

  • Air Travel Insurance (a) In the event of death or disability incurred while travelling by commercial aircraft on business of the Employer, regular and auxiliary employees will be covered by the terms and conditions of the Employer blanket insurance policy.

  • Travel Insurance The Employer shall provide and pay the full cost for travel insurance to cover all members of the bargaining unit for all modes of travel, in the amount of $200,000.00. The travel insurance policy shall also cover employees while on union business.

  • INDUSTRIAL INSURANCE It is understood and agreed that there shall be no Industrial Insurance coverage provided for Contractor or any Sub-Contractor of the Contractor by the City. Contractor agrees, as a precondition to the performance of any work under this Agreement and as a precondition to any obligation of the City to make any payment under this Agreement to provide City with a certificate issued by an insurer in accordance with NRS 616B.627 and with a certificate of an insurer showing coverage pursuant to NRS 617.210. It is further understood and agreed by and between City and Contractor that Contractor shall procure, pay for, and maintain the above mentioned industrial insurance coverage at Contractor's sole cost and expense. Should Contractor be self-funded for Industrial Insurance, Contractor shall so notify City in writing prior to the signing of this Contract. City reserves the right to approve said retentions, and may request additional documentation, financial or otherwise, for review prior to the signing of this Contract. MINIMUM LIMITS OF INSURANCE CONTRACTOR shall maintain coverages and limits no less than:

  • ADDITIONAL INSURED ENDORSEMENT AND PRIMARY AND NON-CONTRIBUTORY INSURANCE CLAUSE Supplier agrees to list Sourcewell and its Participating Entities, including their officers, agents, and employees, as an additional insured under the Supplier’s commercial general liability insurance policy with respect to liability arising out of activities, “operations,” or “work” performed by or on behalf of Supplier, and products and completed operations of Supplier. The policy provision(s) or endorsement(s) must further provide that coverage is primary and not excess over or contributory with any other valid, applicable, and collectible insurance or self-insurance in force for the additional insureds.

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