Claim Form i. Within 15 days after receiving a notice of a claim, you or your Dental Provider will be provided with a Claim Form to make claim for Benefits. To make a claim, the form should be completed and signed by the Provider who performed the services, and by the patient (or the parent or guardian if the patient is a minor), and submitted to the address above.
Claim Form. Whenever an injury on the job is reported, a copy of this section shall be attached to the departmental form (currently the Supervisor’s Incident Investigation Report form), and then provided to the employee. Employees are not required to sign or attest to the SIIR form (or its successor).
Claim Form. The Settlement Class Notice will include the Claim Form, in a form substantially similar to the one attached to the Settlement Agreement as Exhibit “B,” which will inform the Settlement Class Member that he/she must fully complete and timely return the Claim Form and supporting documents within the Claim Period to be eligible to obtain a recovery.
Claim Form. Vir meer inligting besoek: / For more information please visit: / Inkcukach ezithe vetshe uzakuzifumana aph: The Department of Trade and Industry: xxxx://xxx.xxxxxx.xxx.xx/ South African National Accreditation System: xxxx://xxx.xxxxx.xx.xx/directory.php Independent Regulatory Board of Auditors: xxxx://xxxx.xx.xx/index.php ………………………………………………………………………………………………………………………….. Besigheid of persoon se naam:- / Business or person's name:- / Igama leshishini okanye lomntu % **1. Persentasie aandeelhouding van persone (HBI) in die besigheid wat histories benadeel is as gevolg van onregverdige diskriminasie gebaseerd op ras. Percentage of shareholding of persons (HDI) in the business historically disadvantaged because of unfair discrimination based on race. Ipersenti yesabelo sabantu kwishishini elalisakuthinteleka ekuxhamleni amalungelo athile ngenxa yobandlululo ngokobuhlanga. %
Claim Form. Each Settlement Class Member shall be entitled to submit a Claim for Settlement Payment as described in this section.
Claim Form. “Claim Form” shall mean a form in substantially the same form as that attached hereto as Exhibit A.
Claim Form. The Long Form Notice shall describe the Claim Form and shall inform the Settlement Class Member: (i) the criteria to be used to determine whether the Settlement Class Member may select Tier 1, Tier 2, or Tier 3 payments; and (ii) that in order to claim any payment pursuant to the Settlement, the Settlement Class Member must fully complete and timely submit the Claim Form prior to the Claim Deadline.
Claim Form. The Class Notice shall include the Claim Form, which shall inform each Class Member that he or she must fully complete and timely return the Claim Form within the Claim Period to be eligible to obtain relief pursuant to this Agreement.
Claim Form. “Claim Form” means the proof of claim agreed to by the Parties and to be submitted for approval by the Court which shall be used by certain Class Members as described herein to file a claim under this Agreement. A copy of the Claim Form is attached hereto as Exhibit 1.
Claim Form. To be entitled to receive a Settlement Payment from the Net Cash Fund, Class Members must accurately complete a Claim Form, signed under penalty of perjury, and deliver that form to the Claims Administrator no later than one hundred thirty-five (135) calendar days after the entry of the Preliminary Approval Order. The Claim Form must be in the form attached as Exhibit D, and must include certifications acknowledged by Class Members under penalty of perjury that at the time the Class Member was enrolled, he/she did not knowingly authorize his/her enrollment in the Membership Program(s) for which he/she was charged and did not use any of the benefits of the Membership Program(s) other than the dollar-off-code for a future Provide Commerce website purchase. The Claim Form may be submitted electronically or by U.S. mail. The electronic Claim Form on the webpage shall be programmed such that if the Claimant fails to fulfill any of the information or certification requirements before clicking on the “submit” button, the page will immediately display a conspicuous warning window or page in the middle of the screen informing the Claimant of such failure, specifying the deficiency, and explaining that failure to remedy the deficiency will prevent submission of the Claim Form unless remedied. The Claims Administrator shall also take all reasonable actions to contact any Claimant who submits a deficient Claim Form on paper via U.S. Mail. The deficiency notice for a paper Claim Form shall expressly state which pieces of information or certifications must be completed or made for the claim to be deemed non-deficient. The delivery date is deemed to be the date (a) the Claim Form is deposited in the U.S. mail as evidenced by the postmark, in the case of submission by U.S. mail, or by date of delivery if sent by FedEx, UPS, or comparable courier, or (b) in the case of submission electronically through the Internet website for the Settlement, the date the Claims Administrator receives the Claim Form, as evidenced by the transmission receipt. Any Class Member who fails to submit a valid and timely Claim Form is not an Authorized Claimant and will not receive a Settlement Payment from the Net Cash Fund.
