Patient Enrollment Form

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Patient Enrollment Form"

Transcription

1 Patiet Erollmet Form 1 HEALTHCARE PROFESSIONAL (HCP) HCP Name Facility Name Address City State Zip Tel ( ) Fax ( ) HCP NPI# Facility Cotact(s)* * By icludig a facility cotact ame other tha the HCP, the HCP is authorizig the facility cotact to accurately relay HCP directios to JANSSEN CONNECT. The HCP will provide appropriate oversight to esure orders are accurately relayed ad that the HCP is iformed about all program iformatio relevat to the cliical care of the patiet. Facility Cotact Tel ( ) Facility Type: Ipatiet/Hospital Correctioal Outpatiet Cliic Telepsychiatry Private Practice Other 2 PRESCRIPTION Patiet Name DOB / / Sex: Male Female Patiet Address Pref. Laguage: Eglish Spaish City State Zip Other Tel ( ) Diagosis/ICD Code Is patiet ew to this medicatio? Please list ay kow drug allergies Yes No Check here if a copy of the prescriptio is attached ad sig below INVEGA SUSTENNA (paliperidoe palmitate) 39 mg, 78 mg, 117 mg, 156 mg, 234 mg Day 1 Dose mg IM Date Needed Day 8 Dose mg IM Date Needed Maiteace Dose mg IM every 4 weeks Date Needed #Refills Directios OR INVEGA TRINZA TM (paliperidoe palmitate) 273 mg, 410 mg, 546 mg, 819 mg Dose mg IM every 3 moths Date Needed #Refills Directios OR RISPERDAL CONSTA (risperidoe) 12.5 mg, 25 mg, 37.5 mg, 50 mg Dose mg IM every 2 weeks Qty Date Needed #Refills Directios SIGN HERE I certify that the above medicatio is medically ecessary ad that the iformatio provided is accurate to the best of my kowledge. By my sigature, I also ackowledge that I have obtaied the patiet s authorizatio to release the above iformatio ad such other iformatio as may be required by JANSSEN CONNECT to provide the offerigs selected. I appoit JANSSEN CONNECT, o my behalf, to covey this prescriptio to the dispesig pharmacy of the patiet s choice. I further certify that (a) ay offerig provided through JANSSEN CONNECT o behalf of ay patiet is ot made i exchage for ay express or implied agreemet or uderstadig that I would recommed, prescribe, or use JANSSEN CONNECT or ay other product or service for ayoe, ad that (b) my decisio to prescribe the products set forth o this page ad request JANSSEN CONNECT offerigs for my patiet was based solely o my determiatio of medical ecessity as set forth herei, ad that (c) I will ot seek reimbursemet for ay offerig provided by or through JANSSEN CONNECT from ay govermet program or third-party isurer. X / / X / / Dispese as Writte Date Substitutio Accepted Date X / / Supervisig Physicia Sigature Date Supervisig Physicia Name (if applicable) (prit ame) This prescriptio is oly valid if received by fax, meetig state regulatios. Commets: PAGE 1 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

2 3 4 5 Patiet Erollmet Form ALTERNATE PATIENT CONTACT (optioal) This cotact iformatio will be used to coordiate care services if the patiet caot be reached or is uable to maage his/her care. See full Patiet Authorizatio for JANSSEN CONNECT o page 3 of this erollmet packet for a full descriptio of what may be discussed with the alterate cotact listed below. Name Relatioship to Patiet Tel ( ) INSURANCE Primary Isurace Name Tel ( ) Cardholder Name Policy# Group# Check here if you re attachig a copy of the isurace card(s) If patiet has a separate prescriptio coverage pla, please list below. Prescriptio Pla Name Tel ( ) Policy Group# Bi# PCN# Istat Savigs Card: Please provide a Istat Savigs Card for my patiet. To the best of my kowledge, patiet has commercial isurace that covers medicatio costs ad is ot erolled i federal or state subsidized healthcare programs that cover prescriptio drugs, icludig Medicare, Medicaid, TRICARE, or ay other federal or state healthcare pla, icludig pharmaceutical assistace programs. We uderstad ad agree that a beefit verificatio will be performed ad a Istat Savigs Card will ot be provided if eligibility caot be verified Patiet requests that associated Istat Savigs Card iformatio be provided to pharmacy alog with their isurace iformatio if appropriate PROGRAM OFFERINGS Check the box ext to the offerigs you would like for your patiet. BENEFIT VERIFICATION Research my patiet s Jasse log-actig ijectable atypical atipsychotics coverage status Prior Authorizatio Form Assistace: By checkig this, I request that JANSSEN CONNECT assist my office i addressig the requiremets of this patiet s health pla related to prior authorizatio for treatmet with INVEGA TRINZA TM, INVEGA SUSTENNA, ad/or RISPERDAL CONSTA. I uderstad that assistace may iclude obtaiig the health-pla-specific prior authorizatio form, ad completig it based upo the patiet-specific iformatio provided o this form. I uderstad that the partially completed prior authorizatio form will be provided to my office by JANSSEN CONNECT for possible submissio to the health pla Prior Authorizatio Status Moitorig: By checkig this box, I request that JANSSEN CONNECT actively moitor the status of the prior authorizatio submissio. I request that JANSSEN CONNECT provide status updates to my office with respect to this PATIENT TRANSITION SUPPORT Provide iformatio ad assistace to help my patiet trasitio to the ext healthcare settig Facility Name Facility Cotact(s) Address Tel ( ) City State Zip Check this box if JANSSEN CONNECT should schedule patiet s iitial appoitmet, which icludes a remider alert MEDICATION SHIPMENT* Provide assistace i coordiatig my patiet s medicatio shipmet to my office Ship to HCP s secodary locatio at City State Zip *By selectig Medicatio Shipmet, I uderstad that Prior Authorizatio Status Moitorig will also be provided, if applicable INJECTION CENTER OPTIONS WITH REMINDER ALERTS* (if available i your geography) Fax me a list of available locatios Select a locatio closest to my patiet Cotact my patiet to select a locatio REMINDER ALERTS ONLY Please provide remider alerts for my patiets who will be receivig ijectios i my office Use the followig approved JANSSEN CONNECT locatio By amig the above locatio, I attest that I do ot have a fiacial relatioship with the ijectio ceter listed *By selectig Ijectio Ceter Optios, I uderstad that Prior Authorizatio Status Moitorig will also be provided, if applicable PAGE 2 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. My patiet s ext ijectio at my office is scheduled for: Date / / at : AM PM Jasse Pharmaceuticals, Ic May

3 Patiet Erollmet Form HIPAA Authorizatio for JANSSEN CONNECT I hereby authorize the use ad/or disclosure of my private health iformatio, described below, which icludes Protected Health Iformatio as defied i federal laws called the Privacy Regulatios developed uder the Health Isurace Portability ad Accoutability Act of 1996 (as ameded, HIPAA ). I geeral terms, I uderstad that Protected Health Iformatio is health iformatio that idetifies me or that could be used to idetify me. I uderstad that this authorizatio is volutary. The followig perso(s) or class of persos are authorized to disclose this iformatio: 1. Physicias or other healthcare providers that have provided treatmet or services to me. I uderstad that pharmacies that ship my medicatio may be paid to share this iformatio with JANSSEN CONNECT to help provide the offerigs requested for me. 2. The compay admiisterig JANSSEN CONNECT, which at the time of this authorizatio is Uited BioSource Corporatio (referred to herei as JANSSEN CONNECT ). 3. My health pla or other third-party payer. 4. Physicias ad other healthcare providers as directed by the healthcare professioal erollig me i JANSSEN CONNECT. The followig perso(s) or class of persos are authorized to receive the iformatio: 1. JANSSEN CONNECT. 2. My health pla or other third-party payer. 3. Third parties that assist JANSSEN CONNECT with the provisio of patiet offerigs for JANSSEN CONNECT. Descriptio of the iformatio that may be used ad/or disclosed: My diagosis, prescribed therapy (eg, INVEGA SUSTENNA [paliperidoe palmitate], INVEGA TRINZA TM [paliperidoe palmitate], or RISPERDAL CONSTA [risperidoe]), ad a descriptio of the patiet offerigs I have requested or received from JANSSEN CONNECT. I uderstad that the iformatio disclosed about me may iclude metal health iformatio ad/or records. The iformatio will be used ad/or disclosed for the followig purpose(s): 1. For the provisio of the JANSSEN CONNECT patiet offerigs requested, such as ivestigatig my prescribed therapy coverage status, assistig with uderstadig prior authorizatio or appeal requiremets, providig iformatio ad assistace to help my trasitio to my ext healthcare settig, assistig i coordiatig my medicatio shipmet, helpig me PAGE 3 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

4 Patiet Erollmet Form HIPAA Authorizatio for JANSSEN CONNECT (cotiued) determie additioal ijectio ceter optios, ad providig welcome ad remider alerts. 2. I respose to a court order, subpoea, or otherwise required by law. Redisclosure: I uderstad that the Protected Health Iformatio disclosed pursuat to this authorizatio may be redisclosed by JANSSEN CONNECT, for the purposes outlied above to my health pla(s) or other third-party payer(s), my healthcare providers, JANSSEN CONNECT cotractors, ad ay idividual I desigate as a alterate cotact, ad I specifically authorize such redisclosures. Rights ad Other Terms: 1. Iability to Coditio Treatmet, Paymet, Erollmet, or Eligibility for Beefits o Provisio of Authorizatio. I uderstad that my healthcare providers ad health pla(s) may ot coditio my treatmet, paymet, eligibility for beefits, or erollmet i the health pla upo my sigig this authorizatio. 2. Copy of Authorizatio. I uderstad that I am etitled to a siged copy of this authorizatio. 3. Expiratio of Authorizatio. I uderstad that this authorizatio shall expire either whe I stop receivig JANSSEN CONNECT patiet offerigs, or 10 years from the date of this authorizatio, whichever occurs first. 4. Right to Revoke Authorizatio. I uderstad that I may revoke (ie, take back) this authorizatio at ay time except to the extet the recipiets of my iformatio have already take actio i reliace o my authorizatio. To revoke, I uderstad that I must otify JANSSEN CONNECT i writig at the followig toll-free fax umber: HIPAA. I uderstad that the persos who receive my health iformatio pursuat to this authorizatio may ot be required by federal law (such as HIPAA) to protect it, ad may share my iformatio with others if permitted by applicable law. 6. Review Iformatio Disclosed. I uderstad that I have the right to review the iformatio that has bee disclosed pursuat to this authorizatio upo writte request to JANSSEN CONNECT at the followig toll-free fax umber: By sigig this form, I represet that I have read this authorizatio form ad that I uderstad ad agree with what it says. SIGN HERE Patiet Name Legal Authorized Represetative Name X / / X / / Patiet Sigature Date Legal Authorized Represetative Sigature Date PAGE 4 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

5 Patiet Erollmet Form HIPAA Authorizatio for Marketig Activities I have erolled i the JANSSEN CONNECT program ad have authorized certai health iformatio about me to be disclosed to the compay that admiisters JANSSEN CONNECT, which at the time of this authorizatio is Uited BioSource Corporatio (referred to herei as JANSSEN CONNECT ). This health iformatio ( Persoal Iformatio ) icludes iformatio about: My diagosis. The therapy prescribed to me (eg, INVEGA SUSTENNA [paliperidoe palmitate], INVEGA TRINZA TM [paliperidoe palmitate], or RISPERDAL CONSTA [risperidoe]). The patiet offerigs I have received from JANSSEN CONNECT. This Persoal Iformatio may reveal metal-health-related iformatio about me. I ow hereby authorize JANSSEN CONNECT to use my Persoal Iformatio to: Sed me educatioal ad marketig materials regardig the JANSSEN CONNECT program, my prescribed therapy, ad other related products or offerigs i which I might be iterested. Cotact me to obtai feedback about Jasse Pharmaceuticals, Ic., Uited BioSource Corporatio or aother admiistrator of the program, the JANSSEN CONNECT program, ad my prescribed therapy. Maage ad improve the JANSSEN CONNECT program. Respod to a court order, subpoea, or as otherwise required by law. This iformatio ad cotact may occur by phoe, text, , or postal mail uless I request otherwise from JANSSEN CONNECT. I uderstad that JANSSEN CONNECT will oly share my Persoal Iformatio with third parties that provide support for JANSSEN CONNECT pursuat to cotracts where those third parties agree to use the iformatio oly as described i this authorizatio, or as required by law or legal process. I uderstad that, with respect to this authorizatio: I sig this authorizatio volutarily. I uderstad that I may refuse to sig this authorizatio. I uderstad that JANSSEN CONNECT will receive paymet from Jasse Pharmaceuticals, Ic., for providig me with the iformatio ad materials described i this authorizatio. I am etitled to a siged copy of this authorizatio for my records. I may revoke this authorizatio i writig at ay time, except to the extet that actio has already bee take i reliace upo this authorizatio, ad PAGE 5 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

6 Patiet Erollmet Form HIPAA Authorizatio for Marketig Activities (cotiued) if ot earlier revoked, this authorizatio will termiate o the sooer of (i) whe I stop receivig JANSSEN CONNECT patiet offerigs, or (ii) 10 years from the date of this authorizatio. To revoke, I uderstad that I must otify JANSSEN CONNECT i writig at the followig toll-free fax umber: I uderstad that ay revocatio will ot apply to iformatio that has already bee used ad released i respose to this authorizatio. The persos who receive my health iformatio pursuat to this authorizatio may ot be required by federal law (such as HIPAA) to protect it, ad may share my iformatio with others if permitted by applicable law. I uderstad that I have the right to review ay iformatio that has bee disclosed pursuat to this authorizatio upo writte request to JANSSEN CONNECT at the followig toll-free fax umber: By sigig this form, I represet that I have read this authorizatio form ad that I uderstad ad agree with what it says. SIGN HERE Patiet Name Legal Authorized Represetative Name X / / X / / Patiet Sigature Date Legal Authorized Represetative Sigature Date Patiet PAGE 6 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

7 Patiet Erollmet Form HIPAA Authorizatio for Sharig JANSSEN CONNECT Patiet Data With Payer I have erolled i the JANSSEN CONNECT program ad have authorized certai health iformatio about me to be disclosed to the compay that admiisters JANSSEN CONNECT, which at the time of this authorizatio is Uited BioSource Corporatio (referred to herei as JANSSEN CONNECT ). This health iformatio ( Persoal Iformatio ) icludes iformatio about: My diagosis. The therapy prescribed to me (eg, INVEGA SUSTENNA [paliperidoe palmitate], INVEGA TRINZA TM [paliperidoe palmitate], or RISPERDAL CONSTA [risperidoe]). The patiet offerigs I have received from JANSSEN CONNECT. This Persoal Iformatio may reveal metal-health-related iformatio about me. I ow hereby authorize JANSSEN CONNECT to disclose this Persoal Iformatio to my health pla ad its affiliates for purposes of: My case maagemet ad care coordiatio. The health pla s ow data aalysis, icludig to help my health pla to uderstad how I ad others have used the JANSSEN CONNECT program, ad how the JANSSEN CONNECT program has impacted my healthcare ad the care of others participatig i the JANSSEN CONNECT program ad the cost of such healthcare. I uderstad that my health pla may create reports that do ot idetify me to share with JANSSEN CONNECT. I uderstad that JANSSEN CONNECT will ot share my Persoal Iformatio with ay other party for these purposes, except cotractors who provide support for JANSSEN CONNECT pursuat to cotracts where those cotractors agree to use the iformatio oly as described i this authorizatio, or as otherwise required by law. I uderstad that, with respect to this authorizatio: I sig this authorizatio volutarily. I uderstad that I may refuse to sig this authorizatio. I am etitled to a siged copy of this authorizatio for my records. I may revoke this authorizatio i writig at ay time, except to the extet that actio has already bee take i reliace upo this authorizatio, ad if ot earlier revoked, this authorizatio will termiate o the sooer of (i) whe I stop receivig JANSSEN CONNECT patiet offerigs, or (ii) 10 years from the date of this authorizatio. To revoke, I uderstad that I must otify JANSSEN CONNECT i writig at the followig toll-free fax umber: I uderstad that ay revocatio will ot apply to iformatio that has already bee used ad released i respose to this authorizatio. PAGE 7 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

8 Patiet Erollmet Form HIPAA Authorizatio for Sharig JANSSEN CONNECT Patiet Data With Payer (cotiued) The persos who receive my health iformatio pursuat to this authorizatio may ot be required by federal law (such as HIPAA) to protect it, ad may share my iformatio with others if permitted by applicable law. I uderstad that I have the right to review ay iformatio that has bee disclosed pursuat to this authorizatio upo writte request to JANSSEN CONNECT at the followig toll-free fax umber: By sigig this form, I represet that I have read this authorizatio form ad that I uderstad ad agree with what it says. SIGN HERE Patiet Name Legal Authorized Represetative Name X / / X / / Patiet Sigature Date Legal Authorized Represetative Sigature Date PAGE 8 of 8 Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

9 Disclaimer: Iformatio ad assistace (eg, iformatio regardig access ad reimbursemet, the ipatiet/ outpatiet appoitmet gap, medicatio shipmet, additioal ijectio ceter optios, ad followthrough of healthcare professioal-directed treatmet pla) are provided by Uited BioSource Corporatio ( UBC ), uder cotract for Jasse Pharmaceuticals, Ic. ( JPI ). A Patiet Erollmet Form, with sectios completed for requested iformatio regardig assistace, must be submitted to UBC by the healthcare professioal ( HCP ) i order to activate ay JANSSEN CONNECT assistace. No other forms for request for access to JANSSEN CONNECT will be accepted. Assistace caot be directly requested by the patiet. JANSSEN CONNECT is ot available to patiets participatig i a Patiet Assistace Program. The availability of iformatio ad assistace may vary based o geography. UBC provides iformatio to HCPs regardig whether the treatmet is covered by the applicable thirdparty payer, based o the payer s coverage guidelies ad the patiet iformatio provided by the HCP. This iformatio ad assistace are made available as a coveiece to patiets, ad there is o requiremet that patiets or HCPs use ay JPI or other Johso & Johso product i exchage for this iformatio or assistace. Third-party reimbursemet is affected by may factors. This documet ad the iformatio ad assistace provided by JANSSEN CONNECT are preseted for iformatioal purposes oly. They do ot costitute reimbursemet or legal advice. JANSSEN CONNECT does ot promise or guaratee coverage, levels of reimbursemet, or paymet. Similarly, all CPT* ad HCPCS codes are supplied for iformatioal purposes oly ad represet o statemet, promise, or guaratee expressed or implied by JPI or UBC that these codes will be appropriate or that reimbursemet will be made. The fact that a drug, device, procedure, or service is assiged a HCPCS code ad a paymet rate does ot imply coverage by the Medicare program, but idicates oly how the product, procedure, or service may be paid if covered by the Medicare program. Laws, regulatios, ad policies cocerig reimbursemet are complex ad are updated frequetly. Accordigly, the iformatio may ot be curret or comprehesive. JPI ad UBC strogly recommed you cosult your payer for its most curret coverage, reimbursemet, ad codig policies. UBC ad JPI make o represetatios or warraties, expressed or implied, as to the accuracy of the iformatio provided. I o evet shall UBC or JPI, or their employees or agets, be liable for ay damages resultig from or relatig ay iformatio provided by or access to or through JANSSEN CONNECT. All HCPs ad other users of this iformatio agree that they accept resposibility for the use of this program. JPI assumes o resposibility for ad does ot guaratee the quality, scope, or availability of the iformatio ad assistace provided (eg, iformatio regardig access ad reimbursemet, the ipatiet/outpatiet appoitmet gap, medicatio shipmet, additioal ijectio ceter optios, ad follow-through of HCP-directed treatmet pla). UBC, ot JPI, is resposible for the iformatio ad assistace it provides uder this program. Each HCP ad patiet is resposible for verifyig or cofirmig ay iformatio provided by UBC or JPI. All claims ad other submissios to payers should be i compliace with all applicable requiremets. *CPT Curret Procedural Termiology, copyright of the America Medical Associatio, Questios? Call us: AM to 7 PM CT, Moday to Friday. Jasse Pharmaceuticals, Ic May

10 Patiet Erollmet Form FAX DATE PAGES SUBJECT JANSSEN CONNECT PATIENT ENROLLMENT FAX# PHONE# FROM FAX# Please fid the followig attached: Page 1... Healthcare Professioal (HCP) Iformatio ad Prescriptio (REQUIRED) Page 2... Patiet Isurace Iformatio ad Program Offerigs (REQUIRED) Pages HIPAA Authorizatio for JANSSEN CONNECT (REQUIRED) Pages HIPAA Authorizatio for Marketig Activities Pages HIPAA Authorizatio for Sharig JANSSEN CONNECT Patiet Data With Payer Jasse Pharmaceuticals, Ic May

Flexible Spending Account

Flexible Spending Account Health Care Flexible Spedig Accout 800522 d 08/10 what is a health care flexible spedig accout? A health care flexible spedig accout is a easy, coveiet way to get more out of your paycheck. It allows you

More information

Health and dental coverage that begins when your group health benefits end

Health and dental coverage that begins when your group health benefits end Health ad detal coverage that begis whe your group health beefits ed Uderwritte by The Maufacturers Life Isurace Compay Page 1 of 5 FollowMeTM Health ca be your solutio. Life is full of chages. Some are

More information

I apply to subscribe for a Stocks & Shares ISA for the tax year 20 /20 and each subsequent year until further notice.

I apply to subscribe for a Stocks & Shares ISA for the tax year 20 /20 and each subsequent year until further notice. IFSL Brooks Macdoald Fud Stocks & Shares ISA Trasfer Applicatio Form IFSL Brooks Macdoald Fud Stocks & Shares ISA Trasfer Applicatio Form Please complete usig BLOCK CAPITALS ad retur the completed form

More information

I apply to subscribe for a Stocks & Shares NISA for the tax year 2015/2016 and each subsequent year until further notice.

I apply to subscribe for a Stocks & Shares NISA for the tax year 2015/2016 and each subsequent year until further notice. IFSL Brooks Macdoald Fud Stocks & Shares NISA trasfer applicatio form IFSL Brooks Macdoald Fud Stocks & Shares NISA trasfer applicatio form Please complete usig BLOCK CAPITALS ad retur the completed form

More information

MainStay Funds IRA/SEP/Roth IRA Distribution Form

MainStay Funds IRA/SEP/Roth IRA Distribution Form MaiStay Fuds IRA/SEP/Roth IRA Distributio Form Do ot use for IRA Trasfers or SIMPLE IRA INSTRUCTIONS Before completig this form, please refer to the applicable Custodial Agreemet ad Disclosure Statemet

More information

Savings and Retirement Benefits

Savings and Retirement Benefits 60 Baltimore Couty Public Schools offers you several ways to begi savig moey through payroll deductios. Defied Beefit Pesio Pla Tax Sheltered Auities ad Custodial Accouts Defied Beefit Pesio Pla Did you

More information

Florida Governor Rick Scott Signs Senate Bill 408 Into Law

Florida Governor Rick Scott Signs Senate Bill 408 Into Law JUNE 2011 Florida Goveror Rick Scott Sigs Seate Bill 408 Ito Law Florida Goveror Rick Scott siged Seate Bill 408 (SB408) ito law o May 17, 2011. The legislative itet of SB408 is to reform the ustable property

More information

5/gallon. Earn. Then save. Cash Management. Control. Must Apply by 6/30/16. Save 25 /gallon on fuel purchases for the first 2 billing periods * ; then

5/gallon. Earn. Then save. Cash Management. Control. Must Apply by 6/30/16. Save 25 /gallon on fuel purchases for the first 2 billing periods * ; then Ear The save 25/gallo for the first 2 billig periods o fuel purchases with the ExxoMobil Busiess Card. * No miimum purchase requiremets ad o maximum savigs cap. Limited-time offer. Must apply by 6/30/16.

More information

Generali Worldwide Group Health Insurance Health Insurance Application Form

Generali Worldwide Group Health Insurance Health Insurance Application Form Geerali Worldwide Group Health Isurace Health Isurace Applicatio Form Please complete all sectios i BLOCK CAPITALS or tick the boxes, where appropriate. A completed Health Isurace Applicatio is required

More information

There s Wealth in Our Approach.

There s Wealth in Our Approach. Electroic Fud Trasfers/ Automated Clearig House Services There s Wealth i Our Approach. A divisio of RBC Capital Markets, LLC, Member NYSE/FINRA/SIPC. Electroic Fud Trasfers/Automated Clearig House Services

More information

ASSOCIATION LIFE INSURANCE THROUGH THE ISMA INSURANCE AGENCY

ASSOCIATION LIFE INSURANCE THROUGH THE ISMA INSURANCE AGENCY ASSOCIATION LIFE INSURANCE THROUGH THE ISMA INSURANCE AGENCY Thak you for your iterest i the ISMA s Group Term Life Isurace product. Per your request, please fid eclosed the followig: A product brochure

More information

Two people, one policy. Affordable long-term care coverage for both.

Two people, one policy. Affordable long-term care coverage for both. Log-term care rider, available o Natiowide YourLife No-Lapse Guaratee SUL II Feature guide LIFE INSURANCE + LONG-ERM CARE wo people, oe policy. Affordable log-term care coverage for both. NAIONWIDE LIFE

More information

How deductible plans work

How deductible plans work Idividual ad Family Plas DEDUCTIBLE PLANS How deductible plas work Deductible plas geerally offer lower mothly premiums i exchage for payig more out of your ow pocket for services covered by your health

More information

CREATIVE MARKETING PROJECT 2016

CREATIVE MARKETING PROJECT 2016 CREATIVE MARKETING PROJECT 2016 The Creative Marketig Project is a chapter project that develops i chapter members a aalytical ad creative approach to the marketig process, actively egages chapter members

More information

Roles of Pharmacists IN MANAGED HEALTH CARE ORGANIZATIONS. Drug Distribution and Dispensing. Patient Safety

Roles of Pharmacists IN MANAGED HEALTH CARE ORGANIZATIONS. Drug Distribution and Dispensing. Patient Safety Roles of Pharmacists IN MANAGED HEALTH CARE ORGANIZATIONS Drug Distributio ad Dispesig Patiet Safety Cliical Program Developmet Commuicatio with Patiets, Prescribers ad Pharmacists Drug Beefit Desig Busiess

More information

summary of cover CONTRACT WORKS INSURANCE

summary of cover CONTRACT WORKS INSURANCE 1 SUMMARY OF COVER CONTRACT WORKS summary of cover CONTRACT WORKS INSURANCE This documet details the cover we ca provide for our commercial or church policyholders whe udertakig buildig or reovatio works.

More information

For customers Key features of the Guaranteed Pension Annuity

For customers Key features of the Guaranteed Pension Annuity For customers Key features of the Guarateed Pesio Auity The Fiacial Coduct Authority is a fiacial services regulator. It requires us, Aego, to give you this importat iformatio to help you to decide whether

More information

2015 Concordia Health Plan for Medicare Members

2015 Concordia Health Plan for Medicare Members 2015 Cocordia Health Pla for Medicare Members A summary of the beefits, discouts, ad programs for members of the Cocordia Health Pla with Medicare supplemetal coverage. Cocordia Health Pla for Medicare

More information

Cartrefi Hafod Lettings Agency

Cartrefi Hafod Lettings Agency Cartrefi Hafod Lettigs Agecy The ame you ca trust LANDLORD BOOKLET Cartrefi Hafod Lettigs Agecy Cartrefi Hafod Lettigs Agecy offer help to iexperieced ladlords to maage their homes. Hafod Housig Associatio

More information

Computershare Investment Plan. Best Buy Co., Inc. Common Stock

Computershare Investment Plan. Best Buy Co., Inc. Common Stock Computershare Ivestmet Pla A Direct Stock Purchase ad Divided Reivestmet Pla for Best Buy Co., Ic. Commo Stock Best Buy Co., Ic. is listed o the New York Stock Exchage (Tradig Symbol BBY, CUSIP 086516101)

More information

Wells Fargo Insurance Services Claim Consulting Capabilities

Wells Fargo Insurance Services Claim Consulting Capabilities Wells Fargo Isurace Services Claim Cosultig Capabilities Claim Cosultig Claims are a uwelcome part of America busiess. I a recet survey coducted by Fulbright & Jaworski L.L.P., large U.S. compaies face

More information

Handling. Collection Calls

Handling. Collection Calls Hadlig the Collectio Calls We do everythig we ca to stop collectio calls; however, i the early part of our represetatio, you ca expect some of these calls to cotiue. We uderstad that the first few moths

More information

Season s Greetings. President s Message

Season s Greetings. President s Message News SOLELY FOR BENEFIT December 2012 BOARD OF DIRECTORS PRESIDENT Tret White Pharmacists Associatio of Newfoudlad ad Labrador (PANL) SECRETARY/TREASURER Price Edward Islad Pharmacists Associatio (PEI)

More information

Motor legal expenses. Keep me safe

Motor legal expenses. Keep me safe Motor legal expeses Keep me safe Motor legal expeses This legal expeses isurace is part of your LV= motor isurace policy ad your isurace schedule will cofirm if this cover is icluded. You must read your

More information

Shareholder Information Brochure

Shareholder Information Brochure The Ivestor Service ad Automatic Divided Reivestmet Program for Shareholders of Johso & Johso Shareholder Iformatio Brochure The Program is sposored ad admiistered by Computershare Trust Compay, N.A.,

More information

e-trader user guide Introduction

e-trader user guide Introduction User guide e-trader user guide Itroductio At UK Geeral our aim is to provide you with the best possible propositio for you ad your customers. We believe i offerig brokers a choice of how they trade with

More information

Voluntary Life and AD&D Insurance

Voluntary Life and AD&D Insurance Volutary Life ad AD&D Isurace Date: March 2014 To: All JMA beefit eligible members From: Wells Fargo Isurace Services Re: Volutary Life & Accidetal Death ad Dismembermet (AD&D) isurace If you choose to

More information

RISK TRANSFER FOR DESIGN-BUILD TEAMS

RISK TRANSFER FOR DESIGN-BUILD TEAMS WILLIS CONSTRUCTION PRACTICE I-BEAM Jauary 2010 www.willis.com RISK TRANSFER FOR DESIGN-BUILD TEAMS Desig-builD work is icreasig each quarter. cosequetly, we are fieldig more iquiries from cliets regardig

More information

Maricopa County Community College District

Maricopa County Community College District Maricopa Couty Commuity College District A Guide to Your Flexible Spedig Accout Ope erollmet is November 17- December 5. A Balaced Approach To Savig Time Ad Moey Flexible Spedig Accouts Ope erollmet is

More information

Professional Networking

Professional Networking Professioal Networkig 1. Lear from people who ve bee where you are. Oe of your best resources for etworkig is alumi from your school. They ve take the classes you have take, they have bee o the job market

More information

Saint Mary's College. A Guide to Your Flexible Spending Account. A Balanced Approach To Saving Time And Money

Saint Mary's College. A Guide to Your Flexible Spending Account. A Balanced Approach To Saving Time And Money Sait Mary's College A Guide to Your Flexible Spedig Accout A Balaced Approach To Savig Time Ad Moey Flexible Spedig Accouts Makig the most of your moey. What if you could make your earigs stretch further?

More information

Your 1st Step to Finding Resources for Older Adults

Your 1st Step to Finding Resources for Older Adults Your 1st Step to Fidig Resources for Older Adults Are you iterested i home delivered meals? Do you eed a ride to a doctor s appoitmet? Are you takig care of yourself while takig care of a agig fried or

More information

BUY TO LET MORTGAGE APPLICATION FORM

BUY TO LET MORTGAGE APPLICATION FORM BUY TO LET MORTGAGE APPLICATION FORM STAGE 2 OF 2 Please submit Stage 2 form to upgrade to full applicatio oce customer has read ad accepted the Mortgage Illustratio. Please complete this page if form

More information

Swanson McArthur Physical Therapy

Swanson McArthur Physical Therapy Swanson McArthur Physical Therapy PATIET IFORMATIO SHEET CHART#: AME: DATE: SS#: ADDRESS: CIT: STATE: ZIP: HOME PHOE: CELL PHOE: EMERGEC COTACT AME: EMERGEC COTACT PHOE #: EMAIL ADDRESS: DATE OF BIRTH:

More information

Information about Bankruptcy

Information about Bankruptcy Iformatio about Bakruptcy Isolvecy Service of Irelad Seirbhís Dócmhaieachta a héirea Isolvecy Service of Irelad Seirbhís Dócmhaieachta a héirea What is the? The Isolvecy Service of Irelad () is a idepedet

More information

Revised Special Terms & Conditions

Revised Special Terms & Conditions Call: 0191 505 0033* Lies are ope betwee 9am to 6pm Moday to Friday (excludig UK bak holidays) Email us: customerservice@highyieldaccout.co.uk** Write to us: High Yield Vaquis Bak, Freepost RSGY-CKJA-BKCS,

More information

TIAA-CREF Wealth Management. Personalized, objective financial advice for every stage of life

TIAA-CREF Wealth Management. Personalized, objective financial advice for every stage of life TIAA-CREF Wealth Maagemet Persoalized, objective fiacial advice for every stage of life A persoalized team approach for a trusted lifelog relatioship No matter who you are, you ca t be a expert i all aspects

More information

Best of security and convenience

Best of security and convenience Get More with Additioal Cardholders. Importat iformatio. Add a co-applicat or authorized user to your accout ad you ca take advatage of the followig beefits: RBC Royal Bak Visa Customer Service Cosolidate

More information

Disability Income Insurance

Disability Income Insurance Disability Icome Isurace Admiistered by The Parters Group ad Member Compay Kerr Cruickshak Member Compay: Negotiated Limited Time Offer INDIVIDUAL DISABILITY COVERAGE PROGRAM HIGHLIGHTS: Discouted, Specialty,

More information

PFF2 2015/16. Assessment of Financial Circumstances For parents and partners of students. /SFEngland. /SF_England SFE/PFF2/1516/B

PFF2 2015/16. Assessment of Financial Circumstances For parents and partners of students. /SFEngland. /SF_England SFE/PFF2/1516/B PFF2 2015/16 Assessmet of Fiacial Circumstaces For parets ad parters of studets SFE/PFF2/1516/B /SF_Eglad /SFEglad Who should complete this form? Complete this form if you are: The studet s atural or adoptive

More information

THE UNIVERSITY OF CHICAGO 457(b) DEFERRED COMPENSATION PLAN

THE UNIVERSITY OF CHICAGO 457(b) DEFERRED COMPENSATION PLAN THE UNIVERSITY OF CHICAGO 457(b) DEFERRED COMPENSATION PLAN ENROLLMENT GUIDE 2016 2 Overview 3 How to Eroll 5 Your Cotributios 5 Ivestmets 6 Receivig Your Beefits 7 Additioal Iformatio Overview The Uiversity

More information

Financial. Services Guide. Adviser: Graeme Hood CD, Dip FP, CFP Date of Preparation: 21/11/2005. Head Office Address:

Financial. Services Guide. Adviser: Graeme Hood CD, Dip FP, CFP Date of Preparation: 21/11/2005. Head Office Address: Fiacial Services Guide Adviser: Graeme Hood CD, Dip FP, CFP Date of Preparatio: 21/11/2005 Head Office Address: Fiacial Wisdom Limited (ABN 70 006 646 108) Australia Fiacial Services Licece No. 231138

More information

St. Louis Public Schools

St. Louis Public Schools St. Louis Public Schools A Guide to Your Flexible Spedig Accout A Balaced Approach To Savig Time Ad Moey Flexible Spedig Accouts Makig the most of your moey. What if you could make your earigs stretch

More information

Paramount Insurance Company Small/Large Group Ohio Commercial FLEX Network Benefits Member Handbook

Paramount Insurance Company Small/Large Group Ohio Commercial FLEX Network Benefits Member Handbook Paramout Isurace Compay Small/Large Group Ohio Commercial FLEX Network Beefits Member Hadbook www.paramoutisuracecompay.com Paramout is the health isurace optio that offers a diverse lie of products, a

More information

SOAR. TO NEW HEIGHTS! Sponsor the 2015 Customer Connections Conference October 18 21 n Austin, Tex.

SOAR. TO NEW HEIGHTS! Sponsor the 2015 Customer Connections Conference October 18 21 n Austin, Tex. SOAR TO NEW HEIGHTS! Sposor the 2015 Customer Coectios Coferece October 18 21 Austi, Tex. About APPA ad the Customer Coectios Coferece Get exclusive access to decisio-makers ad decisio-ifluecers The America

More information

International Delegation A summary for financial advisers

International Delegation A summary for financial advisers Iteratioal Delegatio A summary for fiacial advisers Cotets Please ote For fiacial adviser use oly. It should ot be distributed to, or relied upo by, retail cliets. AXA Wealth Iteratioal is the brad used

More information

Paramount Insurance Company Small/Large Group Ohio Commercial HMO Member Handbook

Paramount Insurance Company Small/Large Group Ohio Commercial HMO Member Handbook Paramout Isurace Compay Small/Large Group Ohio Commercial HMO Member Hadbook www.paramoutisuracecompay.com Paramout is the health isurace optio that offers a diverse lie of products, a broad provider etwork,

More information

The Vehicle Warranty Products Code

The Vehicle Warranty Products Code The Vehicle Warraty Products Code Applyig to warraty admiistrators govered by the Tradig Stadards Istitute-approved guidelies Cotets Itroductio 3 Defiitios 4 Advertisig What our promise meas to you 6 What

More information

CGH 306: Supervised Field Training in Public Health. What is a field training experience? What is the purpose of field training requirement?

CGH 306: Supervised Field Training in Public Health. What is a field training experience? What is the purpose of field training requirement? CGH 306: Supervised Field Traiig i Public Health Orietatio ad Aswers to Frequetly Asked Questios What is a field traiig experiece? A itegrative, practical experiece i the CGU MPH program Worth 4 uits of

More information

Bajaj Allianz General Insurance Company Limited

Bajaj Allianz General Insurance Company Limited Bajaj Alliaz Geeral Isurace Compay Limited Regd. Office & Head Office : GE Plaza, Airport Road, Yerawada, Pue - 411 006. PROPOSAL FORM FOR OFFICE COVER Importat : This proposal for isurace will be the

More information

FLEXIBLE GUARANTEE BOND SERIES 2

FLEXIBLE GUARANTEE BOND SERIES 2 FLEXIBLE GUARANTEE BOND SERIES 2 Key features of the Flexible Guaratee Bod Series 2 The Fiacial Coduct Authority is a fiacial services regulator. It requires us, LV=, to give you this importat iformatio

More information

Introducing Your New Wells Fargo Trust and Investment Statement. Your Account Information Simply Stated.

Introducing Your New Wells Fargo Trust and Investment Statement. Your Account Information Simply Stated. Itroducig Your New Wells Fargo Trust ad Ivestmet Statemet. Your Accout Iformatio Simply Stated. We are pleased to itroduce your ew easy-to-read statemet. It provides a overview of your accout ad a complete

More information

Baan Service Master Data Management

Baan Service Master Data Management Baa Service Master Data Maagemet Module Procedure UP069A US Documetiformatio Documet Documet code : UP069A US Documet group : User Documetatio Documet title : Master Data Maagemet Applicatio/Package :

More information

Current Year Income Assessment Form

Current Year Income Assessment Form Curret Year Icome Assessmet Form Academic Year 2015/16 Persoal details Perso 1 Your Customer Referece Number Your Customer Referece Number Name Name Date of birth Address / / Date of birth / / Address

More information

PUBLIC RELATIONS PROJECT 2016

PUBLIC RELATIONS PROJECT 2016 PUBLIC RELATIONS PROJECT 2016 The purpose of the Public Relatios Project is to provide a opportuity for the chapter members to demostrate the kowledge ad skills eeded i plaig, orgaizig, implemetig ad evaluatig

More information

Tenants handbook Booklet 4. Paying your rent. June 2015

Tenants handbook Booklet 4. Paying your rent. June 2015 Teats hadbook Booklet 4 Payig your ret Jue 2015 Your Ret ad other charges Payig your ret ad other charges is a coditio of your teacy. If you do ot pay, you will have broke your teacy agreemet with us.

More information

HSAs the American Fidelity Way:

HSAs the American Fidelity Way: Health Ser vices Admiistratio, LLC HSAs the America Fidelity Way: Kowledge, Experiece, Commitmet With over 30 years experiece i providig pre-tax services, America Fidelity is a pioeer i Sectio 125 flexible

More information

Settling Insurance Claims After a Disaster What you need to know about how to file a claim how the claim process works what s covered and what s not

Settling Insurance Claims After a Disaster What you need to know about how to file a claim how the claim process works what s covered and what s not Settlig Isurace Claims After a Disaster What you eed to kow about how to file a claim how the claim process works what s covered ad what s ot First Steps Cotact your aget or compay immediately. Fid out

More information

Art & Private Client insurance policy SUMMARY OF COVER

Art & Private Client insurance policy SUMMARY OF COVER Art & Private Cliet isurace policy SUMMARY OF COVER 2 SUMMARY OF COVER DIOCESAN SCHOOLS LEGAL EXPENSES INSURANCE ART AND PRIVATE CLIENT POLICY SUMMARY SUMMARY OF COVER 3 Policy ref: ME773 1 07/16 What

More information

Amendments to employer debt Regulations

Amendments to employer debt Regulations March 2008 Pesios Legal Alert Amedmets to employer debt Regulatios The Govermet has at last issued Regulatios which will amed the law as to employer debts uder s75 Pesios Act 1995. The amedig Regulatios

More information

FACTSHEET 1: DEVELOPING A STRATEGIC MANAGEMENT PLAN

FACTSHEET 1: DEVELOPING A STRATEGIC MANAGEMENT PLAN FACTSHEET 1: DEVELOPING A STRATEGIC MANAGEMENT PLAN THIS FACTSHEET RELATES TO QUESTION 2.3 OF THE MSPI (MUSEUM STANDARDS PROGRAMME FOR IRELAND) 1. Itroductio Writig a Strategic Maagemet Pla ca provide

More information

Investing in Stocks WHAT ARE THE DIFFERENT CLASSIFICATIONS OF STOCKS? WHY INVEST IN STOCKS? CAN YOU LOSE MONEY?

Investing in Stocks WHAT ARE THE DIFFERENT CLASSIFICATIONS OF STOCKS? WHY INVEST IN STOCKS? CAN YOU LOSE MONEY? Ivestig i Stocks Ivestig i Stocks Busiesses sell shares of stock to ivestors as a way to raise moey to fiace expasio, pay off debt ad provide operatig capital. Ecoomic coditios: Employmet, iflatio, ivetory

More information

FIRE PROTECTION SYSTEM INSPECTION, TESTING AND MAINTENANCE PROGRAMS

FIRE PROTECTION SYSTEM INSPECTION, TESTING AND MAINTENANCE PROGRAMS STRATEGIC OUTCOMES PRACTICE TECHNICAL ADVISORY BULLETIN February 2011 FIRE PROTECTION SYSTEM INSPECTION, TESTING AND MAINTENANCE PROGRAMS www.willis.com Natioal Fire Protectio Associatio (NFPA) #25 a mai

More information

Individually Managed Account Service APPLICATION FORM

Individually Managed Account Service APPLICATION FORM Idividually Maaged Accout Service APPLICATION FORM July 2015 Applicatio Idividually Maaged Accout Service? How to complete the applicatio form 1. Complete the iformatio required i the Applicatio Form o

More information

About our services and costs

About our services and costs About our services ad costs Cotets Whose products do we offer 2 Ivestmet 2 Isurace 2 Mortgages 2 Which services will we provide you with? 3 Ivestmet 3 Isurace 3 Mortgages 3 What will you have to pay us

More information

Basic Current Account

Basic Current Account Curret Accouts Basic Curret Accout Applicatio form Please fill i the form usig BLOCK CAPITALS ad black ik. Tick ay boxes which apply. Satader is able to provide literature i alterative formats. The formats

More information

BUSINESS GROWTH PLAN EVENT 2016

BUSINESS GROWTH PLAN EVENT 2016 BUSINESS GROWTH PLAN EVENT 2016 The Busiess Growth Pla ivolves the idea geeratio ad strategy developmet eeded to grow a existig busiess. Participats i the Busiess Growth Pla will aalyze their curret busiess

More information

Holiday Park Holiday Home Ownership Code of Practice

Holiday Park Holiday Home Ownership Code of Practice The UK trade body for the tourer, motorhome, holiday home ad park home idustries www.thecc.org.uk Holiday Park Holiday Home Owership Code of Practice For the purchase ad sale of ew ad pre-owed Holiday

More information

2014 Menu of Agency Support Services 17 TOP OF MIND TOUCH POINTS

2014 Menu of Agency Support Services 17 TOP OF MIND TOUCH POINTS 2014 Meu of Agecy Support Services 17 TOP OF MIND TOUCH POINTS Table of Cotets Turig a moolie customer ito a multi-lie customer icreases retetio by 7x! ORGANIC GROWTH Policy Reewal Appoitmet Calls.4 Life

More information

Tell us if you need help because of a disability Ask for a free interpreter

Tell us if you need help because of a disability Ask for a free interpreter Your rights uder Califoria Welfare Programs for people applyig for or receivig public aid i Califoria Tell us if you eed help because of a disability Ask for a free iterpreter 2 Your rights all people

More information

auction a guide to buying at Residential

auction a guide to buying at Residential Residetial a guide to buyig at auctio Allsop is the market leader for residetial ad commercial auctios i the UK Aually sells approximately 1 billio of property at auctio i the UK Holds at least seve residetial

More information

Information Handbook

Information Handbook Iformatio Hadbook This hadbook has bee desiged to aswer questios you may have about the admiistratio of your Health ad Detal Pla. Sectios are icluded o how to make a claim, whe to otify us of chages (such

More information

For customers Income protection the facts

For customers Income protection the facts For customers Icome protectio the facts We ve desiged this documet to give you more iformatio about our icome protectio beefits. It does t form part of ay cotract betwee you ad/or us. This iformatio refers

More information

PUBLIC RELATIONS PROJECT 2015

PUBLIC RELATIONS PROJECT 2015 PUBLIC RELATIONS PROJECT 2015 Supported by MARKETING The purpose of the Public Relatios Project is to provide a opportuity for the chapter members to demostrate the kowledge ad skills eeded i plaig, orgaizig,

More information

DC College Savings Plan Helping Children Reach a Higher Potential

DC College Savings Plan Helping Children Reach a Higher Potential 529 DC College Savigs Pla Helpig Childre Reach a Higher Potetial reach Sposored by Govermet of the District of Columbia Office of the Mayor Office of the Chief Fiacial Officer Office of Fiace ad Treasury

More information

PENSION ANNUITY. Policy Conditions Document reference: PPAS1(7) This is an important document. Please keep it in a safe place.

PENSION ANNUITY. Policy Conditions Document reference: PPAS1(7) This is an important document. Please keep it in a safe place. PENSION ANNUITY Policy Coditios Documet referece: PPAS1(7) This is a importat documet. Please keep it i a safe place. Pesio Auity Policy Coditios Welcome to LV=, ad thak you for choosig our Pesio Auity.

More information

Indexed Survivor Universal Life. Agent product guide 15887 7/10

Indexed Survivor Universal Life. Agent product guide 15887 7/10 Idexed Survivor Uiversal Life Aget product guide 15887 7/10 Idexed Survivor Uiversal Life is a flexible premium survivor uiversal life isurace policy with a idex-liked iterest creditig feature. Buildig

More information

84 www.newcastle.edu.au CRICOS Provider Code: 00109J I UoNI 2011/0025 HOW TO APPLY

84 www.newcastle.edu.au CRICOS Provider Code: 00109J I UoNI 2011/0025 HOW TO APPLY 84 www.ewcastle.edu.au CRICOS Provider Code: 00109J I UoNI 2011/0025 HOW TO APPLY Applicatio procedure Prospective iteratioal studets iterested i applyig for admissio to a Uiversity of Newcastle degree

More information

Solutions Library. AMGA/AVATAR CAHPS for PQRS Survey Program. Leslie Babecki, CAHPS Manager, Avatar Solutions

Solutions Library. AMGA/AVATAR CAHPS for PQRS Survey Program. Leslie Babecki, CAHPS Manager, Avatar Solutions Solutios Library AMGA/AVATAR CAHPS for PQRS Survey Program Leslie Babecki, CAHPS Maager, Avatar Solutios Webiar, August 28, 2015 Sice the Agecy for Healthcare Research ad Quality lauched the CAHPS iitiative

More information

PERSONAL INJURY. What you need to know about your legal rights INFORMATION KIT. Personal Injury Litigators since 1936. www.thomsonrogers.

PERSONAL INJURY. What you need to know about your legal rights INFORMATION KIT. Personal Injury Litigators since 1936. www.thomsonrogers. PERSONAL INJURY INFORMATION KIT Effective: September 1, 2010 What you eed to kow about your legal rights Persoal Ijury Litigators sice 1936. www.thomsorogers.com CONTENTS What you eed to kow........................3

More information

Personal Retirement Savings Accounts (PRSAs) A consumer and employers guide to PRSAs

Personal Retirement Savings Accounts (PRSAs) A consumer and employers guide to PRSAs Persoal Retiremet Savigs Accouts (PRSAs) A cosumer ad employers guide to PRSAs www.pesiosauthority.ie The Pesios Authority Verschoyle House 28/30 Lower Mout Street Dubli 2 Tel: (01) 613 1900 Locall: 1890

More information

Evidence requirements guide June 2016

Evidence requirements guide June 2016 INTERMEDIARIES & INVESTMENT PROFESSIONALS ONLY: NOT FOR PUBLIC DISTRIBUTION Page1of6 Evidece requiremets guide Jue 2016 The followig tables show our stadard documetatio requiremets for evidece. Sectio

More information

Holiday Park Holiday Home Ownership Code of Practice

Holiday Park Holiday Home Ownership Code of Practice The UK trade body for the tourer, motorhome, holiday home ad park home idustries www.thecc.org.uk Holiday Park Holiday Home Owership Code of Practice For the purchase ad sale of ew ad pre-owed Holiday

More information

Grow your business with savings and debt management solutions

Grow your business with savings and debt management solutions Grow your busiess with savigs ad debt maagemet solutios A few great reasos to provide bak ad trust products to your cliets You have the expertise to help your cliets get the best rates ad most competitive

More information

Flood Emergency Response Plan

Flood Emergency Response Plan Flood Emergecy Respose Pla This reprit is made available for iformatioal purposes oly i support of the isurace relatioship betwee FM Global ad its cliets. This iformatio does ot chage or supplemet policy

More information

Planning for Your Hip Replacement Surgery

Planning for Your Hip Replacement Surgery Plaig for Your Hip Replacemet Surgery About Our Uit Welcome to Sata Moica-UCLA Medical Ceter ad Orthopaedic Hospital ad thak you for puttig your trust i us for your hip surgery ad rehabilitatio. This brochure

More information

TD Insurance. Travel Medical Insurance Certificate of Insurance IMPORTANT NOTICE PLEASE READ CAREFULLY

TD Insurance. Travel Medical Insurance Certificate of Insurance IMPORTANT NOTICE PLEASE READ CAREFULLY TD Isurace Travel Medical Isurace Certificate of Isurace Issued by: TD Life Isurace Compay ( TD Life ) uder Group Policy Number TI002 (the Group Policy ) to The Toroto- Domiio Bak (the Policyholder or

More information

2014 Menu of Agency Support Services 10 TOP OF MIND TOUCH POINTS

2014 Menu of Agency Support Services 10 TOP OF MIND TOUCH POINTS 2014 Meu of Agecy Support Services 10 TOP OF MIND TOUCH POINTS Table of Cotets Turig a moolie customer ito a multi-lie customer icreases retetio by 7x! ORGANIC GROWTH Policy Reewal Appoitmet Calls.4 Life

More information

Indiana University Health Benefits Guide 2015

Indiana University Health Benefits Guide 2015 Idiaa Uiversity Health Beefits Guide 2015 Dear IU Health Team Member, Welcome to IU Health! IU Health values the cotributios of every team member. Without team members like you, we would ot be able to

More information

Vitality and the Legal Environment of Wellness

Vitality and the Legal Environment of Wellness Vitality ad the Legal Eviromet of Welless A TECHNICAL BRIEF This documet is made for both iteral ad exteral use. TABLE OF CONTENTS INTRODUCTION...1 THE LAWS AT PLAY...2 THE AFFORDABLE CARE ACT AND WELLNESS

More information

Model Audit Guidelines

Model Audit Guidelines Model Audit Guidelies for Pharmacy Claims 100 North Pitt Street I Suite 400 Alexadria, VA 22314 800 827 2627 I 703 683 8416 Fax 703 683 8417 www.amcp.org ACKNOWLEDGEMENTS The Academy of Maaged Care Pharmacy

More information

Life & Disability Insurance. For COSE Employer Groups with 10+ Employees

Life & Disability Insurance. For COSE Employer Groups with 10+ Employees Life & Disability Isurace For COSE Employer Groups with 10+ Employees Life ad Disability Isurace Offerig a great beefit like life ad disability isurace is a excellet way to help attract ad retai taleted

More information

Advancement FORUM. www.acmaweb.org/advancement CULTIVATING LEADERS IN CASE MANAGEMENT

Advancement FORUM. www.acmaweb.org/advancement CULTIVATING LEADERS IN CASE MANAGEMENT H E A L T H C A R E D E L I V E R Y S Y S T E M C A S E M A N A G E M E N T E D U C A T I O N Advacemet FORUM CULTIVATING LEADERS IN CASE MANAGEMENT DATES AND LOCATIONS LOS ANGELES, CA DECEMBER 11 DALLAS,

More information

Table of Contents. The AMA Advantage. General Information 3. How to Enroll 11. Coverage Details 12. Core Plan 4. Claims Process 12.

Table of Contents. The AMA Advantage. General Information 3. How to Enroll 11. Coverage Details 12. Core Plan 4. Claims Process 12. Table of Cotets Geeral Iformatio 3 Overview 3 Portability 3 Notice to Participats ad Employees 3 Eligibility 3 Core Pla 4 Exteded Health Care 4 Detal 5 Out of Provice Emergecy Travel Beefits 6 Cost-Plus

More information

Part 387. Minimum Levels of Financial Responsibility for Motor Carriers. Interstate and Intrastate Commerce

Part 387. Minimum Levels of Financial Responsibility for Motor Carriers. Interstate and Intrastate Commerce Part 387 Miimum Levels of Fiacial Resposibility for Motor Carriers Iterstate ad Itrastate Commerce 35 Part 387 Miimum Levels of Fiacial Resposibility for Motor Carriers (Iterstate ad Itrastate Commerce)

More information

ADMISSION AND REGISTRATION

ADMISSION AND REGISTRATION 14 Admissio ad Registratio 2 C H A P T E R ADMISSION AND REGISTRATION ADMISSION INFORMATION Admissio to Ohloe College is ope to ayoe who is a high school graduate, has a high school equivalecy certificate

More information

National Institute on Aging. What Is A Nursing Home?

National Institute on Aging. What Is A Nursing Home? Natioal Istitute o Agig AgePage Nursig Homes: Makig The Right Choice Lucille has lived i her home for 33 years. Eve after her husbad died 3 years ago, she was able to maage o her ow. Recetly, she broke

More information

Indiana University Health Benefits Guide 2014

Indiana University Health Benefits Guide 2014 Idiaa Uiversity Health Beefits Guide 2014 Idiaa Uiversity Health Team Member Beefits 2014 Packig luches ad cartig the kids off to school. Puttig i a full day s work. Whippig up dier, the catchig up with

More information

Vision Care Program. Vision Discounts Voluntary Vision Benefits LASIK Discounts

Vision Care Program. Vision Discounts Voluntary Vision Benefits LASIK Discounts Visio Care Program Visio Discouts Volutary Visio Beefits LASIK Discouts Visio Care Program by EyeMed Easy to use Simply visit the participatig provider closest to you ad preset your Visio Care ID card

More information

Flexible Trust. (Settlor as trustee with optional survivorship clause) Your questions answered. What is a trust? What is a Flexible Trust?

Flexible Trust. (Settlor as trustee with optional survivorship clause) Your questions answered. What is a trust? What is a Flexible Trust? Flexible Trust (Settl as trustee with optioal survivship clause) Your questios aswered Uderstadig trusts ad their implicatios ca be pretty complicated. You should always get advice from your legal adviser

More information