Instructions to help you complete your enrollment form for the HPHC Medicare Supplement Plan
|
|
- Kathleen Harrison
- 7 years ago
- Views:
Transcription
1 THIS ENROLLMENT FORM IS IN SECTIONS. PLEASE REMOVE THIS TAB TO SEPARATE THE SECTIONS BEFORE YOU BEGIN. Maine Instuctions to help you complete you enollment fom fo the HPHC Medicae Supplement Plan Thank you fo applying fo membeship to HPHC s Medicae Supplement plan. Thee ae 3 ways to enoll: 1. Enoll online. 2. Enoll ove the phone with a plan epesentative, please call HPHC (4742). 3. Complete a pape enollment fom. Pio to submitting you enollment fom fo pocessing, please take the time to complete the entie enollment fom. If the enollment fom eceived is incomplete, it may be etuned to you fo additional infomation. You ae eligible to apply fo HPHC s Medicae Supplement plan if you meet all of the following equiements: You legal esidence is in the state of Maine. You ae eligible fo Medicae Pat A and Medicae Pat B and enolled in Medicae Pat B. If you ae unde age 65 and you qualify fo Medicae coveage because of a disability. Instuctions: 1. Please choose a plan and effective date fo coveage to begin (i.e. MM/01/YYYY). You effective date begins the 1st of the month and cannot be pio to the date we eceive you application. 2. Please fill in you pesonal infomation. 3. You Medicae infomation: Copy infomation fom you Medicae cad, o attach a copy of you lette of Veification fom the Social Secuity Administation o Raiload Retiement Boad. If you don t have you Medicae infomation, call you local Social Secuity Office to obtain poof of enollment. 4. Read and answe all questions in Section Detemine you Eligibility. Open Enollment You have enolled in Medicae Pat B within the last 6 months. You wee enolled in Medicae Pat B pio to age 65 and tuned 65 within the last 6 months. You Medicae Pat B will become effective within the next 60 days. Guaanteed Issue You have been involuntaily teminated o lost coveage fom a Medicae Advantage Plan, employe etiee plan, COBRA coveage, Medicae Select, PACE, Demonstation o Medicae Supplement plan in the past 90 days. The Havad Pilgim Medicae Supplement plan you ae choosing is of equal o lesse coveage than you cuent Medicae Supplement policy and you have not had a gap in coveage of moe than 90 days. (Please be sue to answe question 4 completely o HPHC may equest poof of coveage). You left you employe etiee plan and ae applying within 90 days of you disenollment date. You voluntaily disenolled fom you Medicae Advantage, Medicae Select o PACE plan within the fist 36 months of enollment, and ae applying fo Medicae Supplement within 90 days of temination. Annual One Month Guaanteed Issue You ae applying fo Plan "A" duing the month of Decembe fo a Januay 1st effective date fo coveage - Section 5 is NOT equied. Continuous Open Enollment You ae applying fo Plans A,F, M, and N at anytime-section 5 must be completed with all "NO" esponses. 6. Read Impotant Infomation in Section Sign and date the enollment fom. 8. If you eceived a notice fom you pio insue saying you wee eligible fo guaanteed issue of a Medicae Supplement Insuance Policy, o that you had cetain ights to buy such a Policy, please include a copy. Detach the yellow copy of this fom fo you legal ecods and mail the white enollment fom to: Havad Pilgim Health Cae Medicae Supplement Plan 93 Woceste Steet, Suite 100, Wellesley, MA If you need assistance o have questions, please call us at: Pospective Membes: HPHC (4742), TTY Fom No Cuent Membes: HPHC (4742), TTY
2 Maine New Enollment Change to Enollment HPHC Medicae Supplement Enollment Fom The Plan is undewitten by HPHC Insuance Company, an affiliate of Havad Pilgim Health Cae. SECTION 1. Plan Choice: Plan A Plan F Plan M Plan N Plan Effective Date SECTION 2. Pesonal Infomation: Fist Name Middle Initial Last Name Social Secuity Numbe Pemanent Addess (Numbe & Steet) City/State/Zip Code Billing Addess (if diffeent fom you pemanent addess) City/State/Zip Code Cuent Insuance Caie Gende Male Female Date of Bith Month Day Yea Telephone Numbe ( ) Addess SECTION 3. Medicae Infomation Please take out you ed, white & blue Medicae Cad to complete this section. MEDICARE HEALTH INSURANCE NAME MEDICARE CLAIM NUMBER SEX IS ENTITLED TO EFFECTIVE DATE HOSPITAL (PART A) MEDICAL (PART B) SECTION 4. Replacement o othe Coveage If you lost o ae losing othe health insuance coveage and eceived a notice fom you pio insue saying you wee eligible fo guaanteed issue of a Medicae Supplement insuance policy, o that you had cetain ights to buy such a policy, you may be guaanteed acceptance in one o moe of ou Medicae Supplement plans. Please include a copy of the notice fom you pio insue with you application. If you wee involuntaily teminated fo nonpayment of pemium, please also include documentation demonstating payment of outstanding pemiums. Fom No Yellow - Applicant - Please keep fo you ecods
3 SECTION 4. continued Please Answe All Questions [Please check Yes o No] To the best of you knowledge, 1. (a) Did you tun age 65 in the last six months? Yes No (b) Did you enoll in Medicae Pat B in the last six months? Yes (c) If yes, what is the effective date? No 2. Ae you coveed fo medical assistance though the state Medicaid pogam? [NOTE TO APPLICANT: If you ae paticipating in a Spend-Down Pogam and have not met you Shae of Cost, please answe NO to this question.] Yes If yes, (a) Will Medicaid pay you pemiums fo this Medicae Supplement policy? Yes (b) Do you eceive any benefits fom Medicaid OTHER THAN payments towad you Medicae Pat B pemium? Yes No (c) Did you lose o will you be losing Medicaid eligibility? Yes No Medicaid temination date No No 3. (a) If you had coveage fom any Medicae plan othe than oiginal Medicae within the past 90 days (fo example, a Medicae Advantage plan, o a Medicae HMO o PPO), fill in you stat and end dates below. If you ae still coveed unde this plan, leave END blank. START / / END / / (b) If you ae still coveed unde the Medicae plan, do you intend to eplace you cuent coveage with this new Medicae Supplement policy? Yes No (c) Was this you fist time in this type of Medicae plan? Yes No (d) Did you dop a Medicae Supplement policy to enoll in the Medicae plan? Yes No 4. (a) Do you have anothe Medicae Supplement policy in foce? Yes No (b) If so, with what company, and what plan do you have? (c) If so, do you intend to eplace you cuent Medicae Supplement policy with this policy? Yes No 5. Have you had coveage unde any othe health insuance within the past 90 days? Yes No (Fo example, an employe, union, o individual plan) (a) If so, with what company and what kind of policy? (b) What ae you dates of coveage unde the othe policy? START / / END / / (If you ae still coveed unde this plan, leave END blank.) Yellow - Applicant - Please keep fo you ecods
4 SECTION 5. IF YOU ARE ELIGIBLE FOR OPEN ENROLLMENT OR GUARANTEE ISSUE (SEE #5 ON THE INSTRUCTION PAGE TO DETERMINE WHETHER THIS SECTION APPLIES TO YOU), DO NOT ANSWER THE QUESTIONS IN THIS SECTION. If the answe to any question in this section is YES the Applicant is not eligible fo coveage. This does not apply to applicants applying fo Medicae Supplement coveage unde Plan A duing the annual one month guaantee issue. Height (feet/inches) Weight (pounds) Ae you now confined in a hospital o nusing home, o, within the past 60 days, have you been advised by a docto to seek medical cae o teatment in a hospital o in a nusing home? Yes No Ae you bedidden? Yes No Do you equie the use of a wheelchai? (if YES, please give details) Yes No Ae you eceiving kidney dialysis? Yes No Have you, due to mental o physical disability, authoized any peson o institution to legally act in you behalf and take ove you pesonal tansactions? Yes No In the past 12 months, have you been advised to have sugey but it has not yet been done? Yes No In the past 12 months, have you been hospitalized thee o moe times? Yes No Do you outinely visit the same medical povide moe than monthly fo medical advice o teatment? Yes No Do you now have any of the following conditions diagnosed by a membe of the medical pofession o have you eceived medical advice o teatment fo the following conditions within the past 12 months? Cance (except skin) o Leukemia Chonic Lung Disease Cihosis of the Live Diabetes (insulin dependent) Stoke Angina Pectois, Heat Attack, Congestive Heat Failue, o Valvula Heat Disease Alzheime s Disease, memoy loss o impaiment, dementia o cognitive impaiment Pakinson s Disease Multiple Scleosis Chonic Kidney Disease Any fom of Athitis o Degeneative Bone Disease which causes cippling, factues, limitation of motion o equiing joint eplacement Yellow - Applicant - Please keep fo you ecods
5 SECTION 6. Impotant Infomation A. You do not need moe than one Medicae Supplement policy. B. If you puchase this policy you may want to evaluate you existing health coveage and decide if you need multiple coveages. C. You may be eligible fo Medicaid benefits and may not need a Medicae Supplement policy. D. If, afte puchasing this policy, you become eligible fo Medicaid, the benefits and pemiums unde you Medicae Supplement policy can be suspended, if equested, duing you entitlement to benefits unde Medicaid fo 24 months. You must equest this suspension within 90 days of becoming eligible fo Medicaid. If you ae no longe entitled to Medicaid, you suspended Medicae Supplement policy (o, if that is no longe available, a substantially equivalent policy) will be einstituted if equested within 90 days of losing Medicaid eligibility. If the Medicae Supplement policy povided coveage fo outpatient pesciption dugs and you enolled in Medicae Pat D while you policy was suspended, the einstituted policy will not have outpatient pesciption dug coveage, but will othewise be substantially equivalent to you coveage befoe the date of the suspension. E. If you ae eligible fo, and have enolled in a Medicae Supplement policy by eason of disability and you late become coveed by an employe o union-based goup health plan, the benefits and pemiums unde you Medicae Supplement policy can be suspended, if equested, while you ae coveed unde the employe o union-based goup health plan. If you suspend you Medicae Supplement policy unde these cicumstances, and late lose you employe o union-based goup health plan, you suspended Medicae Supplement policy (o, if that is no longe available, a substantially equivalent policy) will be einstituted if equested within 90 days of losing you employe o union-based goup health plan. If the Medicae Supplement policy povided coveage fo outpatient pesciption dugs and you enolled in Medicae Pat D while you policy was suspended, the einstituted policy will not have outpatient pesciption dug coveage, but will othewise be substantially equivalent to you coveage befoe the date of the suspension. F. Counseling sevices may be available in you state to povide advice concening you puchase of Medicae Supplement insuance and concening medical assistance though the state Medicaid pogam, including benefits as a Qualified Medicae Beneficiay (QMB) and a Specified Low-Income Medicae Beneficiay (SLMB). Yellow - Applicant - Please keep fo you ecods
6 SECTION 7. I o my authoized epesentative cetify that the statements made and answes given ae complete and tue. I o my authoized epesentative have ead and caefully consideed all of the infomation on this fom. I o my authoized epesentative also cetify that I eceived the Outline of Medicae Supplement Coveage. I o my authoized epesentative undestand that no employe, fome employe, health cae povide, o pivate o govenment agency may sponso, puchase o contibute to the cost of this Havad Pilgim Medicae Supplement Plan. I o my authoized epesentative undestand that to enoll in coveage, and fo as long as I am coveed, I must be entitled to Medicae Pat A and enolled in Medicae Pat B. I o my authoized epesentative undestand that membeship will become effective upon the fist day of the month following acceptance by the Plan. Benefits unde this Plan will be explained unde a sepaate document. I o my authoized epesentative authoize all of my health cae povides, othe health plans, and insuance companies to elease all of my medical ecods and othe infomation to the Plan o to Plan affiliated health cae povides fo the pupose of detemining my coveage and administeing my benefits. I o my authoized epesentative authoize the use by the Plan and its agents, of any infomation obtained heeunde fo the delivey of health sevice, to detemine eligibility and entitlement to benefits (including eimbusement by thid paties) fo education and eseach in accodance with govenment egulations and fo the othe plan pofessional activities such as utilization eview, quality assuance, case management, efeal and authoization, disease management, faud detection, and cetain ovesight activities, such as acceditation and egulatoy audits. I o my authoized epesentative undestand that the benefits fo which I am eligible ae those descibed in the applicable subscibe policy. I o my authoized epesentative undestand that HPHC s Medicae Supplement Insuance pemium ates ae subject to change as allowed by state law. I o my authoized epesentative undestand that enollment in this plan is contingent upon payment of pemium. I o my authoized epesentative is entitled to eceive a copy of this authoization fom. The subogation povision outlined in the Policy, pemits subogation payments on a just and equitable basis. This authoization is valid though the tem of coveage unde the plan o any enewals theeof. You may evoke this authoization at any time by contacting the Plan at the above addess o telephone numbe, povided that such evocation may be a basis fo denying benefits unde the Plan. All statements and infomation in this fom shall be deemed epesentations and not waanties. I undestand that a copy of this fom will be given to me, o my authoized epesentative, upon equest. It is a cime to knowingly povide false, incomplete o misleading infomation to an insuance company fo the pupose of defauding the company. Penalties may include impisonment, fines o a denial of insuance benefits. Failue to sign this fom may impai the Plan s ability to evaluate o pocess an application o claim and may be a basis fo denying an application o a claim fo benefits. _ Signatue of Applicant, o Authoized Repesentative (if applicable)* Date *If signed by an Authoized Repesentative, a copy of the authoity to epesent applicant must be attached to the application (such as a Powe of Attoney). Yellow - Applicant - Please keep fo you ecods
7 SECTION 8. NOTE: THIS SECTION IS ONLY TO BE COMPLETED IF YOU ARE WORKING WITH AN INDEPENDENT INSURANCE AGENT. PLEASE FAX ENROLLMENT FORM TO I, o my authoized epesentative, acknowledge eceipt of Choosing a Medigap Policy: A Guide to Health Insuance fo People with Medicae at the time of my application fo coveage in Havad Pilgim Health Cae s Medicae Supplement Plan. Please Pint: Applicant Name: Applicant Addess: Medicae Claim Numbe : - - Signatue of Applicant, o Authoized Repesentative (if applicable)* Date *If signed by an Authoized Repesentative, a copy of the authoity to epesent applicant must be attached to the application (such as a Powe of Attoney). Please Pint: Agent/Boke Name Agent /Boke ID Agent /Boke Signatue Date Yellow - Applicant - Please keep fo you ecods
8 SECTION 9. NOTE: THIS SECTION IS ONLY TO BE COMPLETED IF YOU ARE WORKING WITH AN INDEPENDENT INSURANCE AGENT AND ARE REPLACING AN EXISTING MEDICARE PLAN. Notice to Applicant Regading Replacement of Medicae Supplement Insuance o Medicae Advantage HPHC Insuance Company 93 Woceste Steet, Wellesley, MA Save this Notice! It May be Impotant to you in the futue. Accoding to the infomation you have funished, you intend to teminate existing Medicae Supplement o Medicae Advantage insuance and eplace it with a policy to be issued by HPHC Insuance Company. You new policy will povide thity (30) days within which you may decide without cost whethe you desie to keep the policy. You should eview this new coveage caefully. Compae it with all accident and sickness coveage you now have. If, afte due consideation, you find that puchase of this Medicae Supplement coveage is a wise decision, you should teminate you pesent Medicae Supplement o Medicae Advantage coveage. You should evaluate the need fo othe accident and sickness coveage you have that may duplicate this policy. STATEMENT TO APPLICANT BY ISSUER, INSURANCE PRODUCER OR OTHER REPRESENTATIVE: I have eviewed you cuent medical o health insuance coveage. To the best of my knowledge, this Medicae Supplement policy will not duplicate you existing Medicae Supplement o, if applicable, Medicae Advantage coveage because you intend to teminate you existing Medicae Supplement coveage o leave you Medicae Advantage plan. The eplacement policy is being puchased fo the following eason(s) (check one): Additional benefits Fewe benefits and lowe pemiums My plan has outpatient pesciption dug coveage and I am enolling in Pat D. Othe (please specify) No change in benefits, but lowe pemiums Disenollment fom a Medicae Advantage plan. Please explain eason fo disenollment. [Optional only fo Diect Mailes] If you still wish to teminate you pesent policy and eplace it with new coveage, be cetain to tuthfully and completely answe all questions on the application concening you medical and health histoy. Failue to include all mateial medical infomation on an application may povide a basis fo the company to deny any futue claims and to efund you pemium as though you policy had neve been in foce. Afte the application has been completed and befoe you sign it, eview it caefully to be cetain that all infomation has been popely ecoded. Do not cancel you pesent policy until you have eceived you new policy and ae sue that you want to keep it. [Signatue of Agent, Boke, o Othe Repesentative] [Typed Name and Addess of Issue, Agent, o Boke] Please Pint: Applicant Name Applicant Addess Signatue of Applicant o Authoized Repesentative (if applicable)* Date *If signed by an Authoized Repesentative, a copy of the authoity to epesent applicant must be attached to the application (such as a Powe of Attoney). Yellow - Applicant - Please keep fo you ecods
Instructions to help you complete your enrollment form for HPHC's Medicare Supplemental Plan
Instuctions to help you complete you enollment fom fo HPHC's Medicae Supplemental Plan Thank you fo applying fo membeship to HPHC s Medicae Supplement plan. Pio to submitting you enollment fom fo pocessing,
More informationHOSPITAL INDEMNITY CLAIM FORM
HOSPITAL INDEMNITY CLAIM FORM Please ead the impotant infomation below: Please send the completed claim fom, signed authoization, and itemized bills to: Please be sue you policy numbe(s) is/ae witten on
More informationCANCER, HEART ATTACK OR STROKE CLAIM FORM
CANCER, HEART ATTACK OR STROKE CLAIM FORM Please ead the impotant infomation below: We suggest you make photocopies of any infomation sent fo you own ecods. Please be sue you policy numbe(s) is/ae witten
More informationThings to Remember. r Complete all of the sections on the Retirement Benefit Options form that apply to your request.
Retiement Benefit 1 Things to Remembe Complete all of the sections on the Retiement Benefit fom that apply to you equest. If this is an initial equest, and not a change in a cuent distibution, emembe to
More informationDOCTORAL DEGREE PROGRAM
DOCTORAL DEGREE PROGRAM Application Fo Admission National Mose Cente fo Adult Leaning Cental Illinois: Benedictine Univesity at Spingfield 1500 Noth 5th Steet, Spingfield, IL 62702 Phone: (217) 718-5002
More informationFirstmark Credit Union Commercial Loan Department
Fistmak Cedit Union Commecial Loan Depatment Thank you fo consideing Fistmak Cedit Union as a tusted souce to meet the needs of you business. Fistmak Cedit Union offes a wide aay of business loans and
More informationDOCTORATE DEGREE PROGRAMS
DOCTORATE DEGREE PROGRAMS Application Fo Admission 2015-2016 5700 College Road, Lisle, Illinois 60532 Enollment Cente Phone: (630) 829-6300 Outside Illinois: (888) 829-6363 FAX: (630) 829-6301 Email: admissions@ben.edu
More informationInstructions to help you complete your enrollment form for the HPHC Medicare Supplement Plan
Instructions to help you complete your enrollment form for the HPHC Medicare Supplement Plan Massachusetts THIS ENROLLMENT FORM IS IN SECTIONS. PLEASE REMOVE THIS TAB TO SEPARATE THE SECTIONS BEFORE YOU
More informationFaithful Comptroller s Handbook
Faithful Comptolle s Handbook Faithful Comptolle s Handbook Selection of Faithful Comptolle The Laws govening the Fouth Degee povide that the faithful comptolle be elected, along with the othe offices
More informationArmored Car Insurance Application
Amoed Ca Insuance Application Applicant Details: Fist named insued: _ Please attach list of any additional insueds to be included fo coveage. Addess: City/State/Zip: Effective date: Expiation date: Additional
More information9:6.4 Sample Questions/Requests for Managing Underwriter Candidates
9:6.4 INITIAL PUBLIC OFFERINGS 9:6.4 Sample Questions/Requests fo Managing Undewite Candidates Recent IPO Expeience Please povide a list of all completed o withdawn IPOs in which you fim has paticipated
More informationImportant Notes About This Guide... 2. Application Packet Checklist... 3. Requirements for Non-Face-to-Face Sales... 3
CREATED EXCLUSIVELY FOR FINANCIAL PROFESSIONALS SERVICE Guide to Completing Life Insuance Applications PURPOSE OF THIS GUIDE This guide povides infomation that will help the use accuately complete the
More informationIgnorance is not bliss when it comes to knowing credit score
NET GAIN Scoing points fo you financial futue AS SEEN IN USA TODAY SEPTEMBER 28, 2004 Ignoance is not bliss when it comes to knowing cedit scoe By Sanda Block USA TODAY Fom Alabama comes eassuing news
More informationApplication for Admission GENEVA COLLEGE
Application fo Admission GENEVA COLLEGE 3 2 0 0 C o l l e g e A v e n u e, B e a v e F a l l s, P A 1 5 0 1 0 Application Instuctions When to apply You may apply fo admission any time afte you junio yea
More information(Sn) J. P. Phillips, J. P. Phillips, Mayor uity of Roanoke, Alabama
304 (Sn) J. P. Phillips, J. P. Phillips, Mayo uity of Roanoke, Alabama "I (Sn) Qlin E. Sheppad Olin E. Sheppad, City Clek City of Roanoke, Alabama I, Olin E. Sheppad, as City Clek of the City of Roanoke,
More informationTransmittal 198 Date: DECEMBER 9, 2005. SUBJECT: Termination of the Existing Eligibility-File Based Crossover Process at All Medicare Contractors
anual ystem Depatment of ealth & uman evices (D) entes fo edicae & Pub 100-20 One-Time Notification edicaid evices () Tansmittal 198 Date: DEEBE 9, 2005 hange equest 4231 UBJET: Temination of the Existing
More informationYour Guide to Homeowners Insurance
You Guide to Homeownes Insuance Fo Michigan Consumes Depatment of Insuance and Financial Sevices (DIFS) Toll-Fee Consume Assistance Line 877-999-6442 www.michigan.gov/difs Table of Contents Undestanding
More informationAFFILIATE MEMBERSHIP APPLICATION
Califonia Constuction Tucking Association AFFILIATE MEMBERSHIP APPLICATION Reach and Netwok with the Lagest Concentation of Constuction Tucking Fims in the U.S. Affiliate Dues - $500 Annual CCTA 334 N.
More informationTransmittal 47 Date: FEBRUARY 24, 2006
anual ystem Pub 100-03 edicae National oveage Deteminations Depatment of Health & Human evices (DHH) ente fo edicae & edicaid evices () Tansmittal 47 Date: EBUAY 24, 2006 hange equest 4257 UBJET: hanges
More informationcover comparison TUH it s my health fund! Your Queensland health fund Effective 2 April 2014
Effective 2 Apil 2014 You Queensland health fund cove compaison TUH it s my health fund! PLEASE CAREFULLY READ AND RETAIN THIS BROCHURE. PLEASE READ IN CONJUNCTION WITH THE Fine Points BROCHURE. waiting
More informationAPPLICATION AND AGREEMENT FORM FOR TELECOMMUNICATION SERVICES BUSINESS APPLICATION
Application Fom SECTION 1 COMPANY DETAILS New Company Yes No Company Name Tading As Pevious Company Name Email Addess Contact Numbe Tel Cell Fax Registeed Numbe Natue of Business Yea of Incopoation Yea
More informationest using the formula I = Prt, where I is the interest earned, P is the principal, r is the interest rate, and t is the time in years.
9.2 Inteest Objectives 1. Undestand the simple inteest fomula. 2. Use the compound inteest fomula to find futue value. 3. Solve the compound inteest fomula fo diffeent unknowns, such as the pesent value,
More informationCOMPLYING WITH THE DRUG-FREE SCHOOLS AND CAMPUSES REGULATIONS
Highe Education Cente fo Alcohol and Othe Dug Abuse and Violence Pevention Education Development Cente, Inc. 55 Chapel Steet Newton, MA 02458-1060 COMPLYING WITH THE DRUG-FREE SCHOOLS AND CAMPUSES REGULATIONS
More informationMedicare Supplement Application Aetna Life Insurance Company Aetna Administrator, P.O. Box 10374, Des Moines, IA 50306
Medicare Supplement Application Aetna Administrator, P.O. Box 10374, Des Moines, IA 50306 INSTRUCTIONS: To be considered complete, all sections on this form must be filled out, unless marked optional.
More informationAPPLICATION FOR MEDICARE SUPPLEMENT COVERAGE
CENTRAL STATES INDEMNITY CO. OF OMAHA Home Office: Omaha, NE Administration: P.O. Box 10816 Clearwater, Florida 33757-8816 APPLICATION FOR MEDICARE SUPPLEMENT COVERAGE SECTION A. PROPOSED INSURED INFORMATION
More informationIn the Supreme Court of British Columbia
26-Ap-11 Vancouve Fom 1 (Rule 3-1(1)) Cout File No. VLC-S-S-112673 Vancouve Registy In the Supeme Cout of Bitish Columbia Between Daniel Veniez Plaintiff And John Weston, Paul Veltmeye, John Doe & Jane
More informationConverting knowledge Into Practice
Conveting knowledge Into Pactice Boke Nightmae srs Tend Ride By Vladimi Ribakov Ceato of Pips Caie 20 of June 2010 2 0 1 0 C o p y i g h t s V l a d i m i R i b a k o v 1 Disclaime and Risk Wanings Tading
More informationm 29 18 OK 62-0662175
vosvw a um 4.' 990.E Z Retun of Oganization Exempt Fom Income Tax Unde section 501(c), 527, o 4947(a)(1) of the Intenal Revenue Code (except black lung benefit tust a pivate foundation) " Do- Fo oganizations
More informationThe impact of migration on the provision. of UK public services (SRG.10.039.4) Final Report. December 2011
The impact of migation on the povision of UK public sevices (SRG.10.039.4) Final Repot Decembe 2011 The obustness The obustness of the analysis of the is analysis the esponsibility is the esponsibility
More informationCENTRAL STATES INDEMNITY CO. OF OMAHA Home Office: Omaha, NE Administration: P.O. Box 10816 Clearwater, Florida 33757-8816
CENTRAL STATES INDEMNITY CO. OF OMAHA Home Office: Omaha, NE Administration: P.O. Box 10816 Clearwater, Florida 33757-8816 APPLICATION FOR MEDICARE SUPPLEMENT COVERAGE SECTION A. PROPOSED INSURED INFORMATION
More informationThank you for your interest in the KPS Health Plans Medicare Supplement plan!
KPS Application Thank you for your interest in the KPS Health Plans Medicare Supplement plan! Attached is a copy of the policy Enrollment Form and we have supplied you with a link to a printable copy of
More informationEnrollment Application for Medicare Supplement
Group Health Options, Inc. PO Box 34803 Seattle, WA 98124-1803 PLAN CHOICE rplan A rplan F rplan K rplan N Enrollment Application for Medicare Supplement PLEASE PRINT Answer all questions completely and
More informationEnrollment Application for Medicare Supplement
Page 1 of 6 PO Box 34803 Seattle, WA 98124-1803 SECTION 1 PLAN CHOICE rplan A (2010 STANDARDIZED) rplan F (2010 STANDARDIZED) rplan K rplan N PLEASE PRINT Answer all questions completely and accurately
More informationFixed Income Attribution: Introduction
18th & 19th Febuay 2015, Cental London Fixed Income Attibution: A compehensive undestanding of Fixed Income Attibution and the challenging data issues aound this topic Delegates attending this two-day
More informationAPPLICATION FOR MEDICARE SUPPLEMENT INSURANCE
301 S. Vine St. APPLICATION FOR MEDICARE SUPPLEMENT INSURANCE Urbana, IL 81801-3347 Member Assigned #: 1-800-965-4022 TTY/TDD 711 or 1-800-526-0844 (Illinois Relay) Effective Date: SECTION 1: APPLICANT(S)
More informationLast name First name Middle initial Social Security number (required)
Alaska Medicare Supplement Enrollment Application for Plans A, F, High Deductible F and N 2550 Denali St., Suite 1404 Anchorage, AK 99503 1-888-669-2583 Fax: 907-258-1619 ou are eligible to apply for a
More informationApplication for Medicare Supplement
Application for Medicare Supplement This application is subject to the approval of Blue Cross and Blue Shield of Nebraska. P.O. Box 2417 Omaha, NE 68103-2417 1 Tell us about yourself. Name (First, Middle,
More informationP.O. Box 91120, MS 295 Seattle, WA 98111-9220 1-800-752-6663 Fax: 425-918-5278
Washington Medicare Supplement Enrollment Application for Plans A, F, High Deductible F and N P.O. Box 91120, MS 295 Seattle, WA 98111-9220 1-800-752-6663 Fax: 425-918-5278 ou are eligible to apply for
More informationHow To Get A Tax Credit From Illinois
Indiana Depatment of Revenue Individual Income Tax Booklet IT-40 Cove Page (Individual Foms ae on the last pages.) What fom do I file? Indiana has fou diffeent individual income tax etuns. See which one
More informationHealth Office 2015-16 STUDENT HEALTH RECORD 508.490.8228 healthforms@fayschool.org
STUDENT HEALTH RECORD 508.490.8228 healthfoms@fayschool.og PARENTS: PLEASE LIST Allegies: Dietay Restictions: Please fill out the following fom completely. This fom includes a pemission statement that
More informationCalifornia s Duals Demonstration: A Transparent. Process. Margaret Tatar Chief, Medi-Cal Managed Care Division. CA Coo 8/21/12
Califonia s Duals Demonstation: A Tanspaent and Inclusive Stakeholde Pocess Magaet Tata Chief, Medi-Cal Managed Cae Division Depatment of Health Cae Sevices 1 Stakeholde Engagement 1. 2. Inclusive Building
More information2015 Medicare Blue Choice (HMO) and (HMO-POS) Individual Enrollment Request Form
2015 Medicare Blue Choice (HMO) and (HMO-POS) Individual Enrollment equest Form Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan with a Medicare contract Enrollment
More informationTexas Application for SecureHorizons Medicare Supplement Plan
Texas Application for SecureHorizons Medicare Supplement Plan Eligibility: To be eligible for this Medicare supplement plan you must be: n Enrolled under Federal Medicare Hospital Insurance (Part A) and
More informationChapter 3 Savings, Present Value and Ricardian Equivalence
Chapte 3 Savings, Pesent Value and Ricadian Equivalence Chapte Oveview In the pevious chapte we studied the decision of households to supply hous to the labo maket. This decision was a static decision,
More informationWELCOME TO OUR NEW NEWSLETTER
ISSUE ONE > JUNE 2013 WELCOME TO OUR NEW NEWSLETTER PARTNERS OUTLOOK Welcome to the band new Patnes Outlook newslette. It s had to believe it s June and anothe end of financial yea is aleady ceeping up.
More informationDefine What Type of Trader Are you?
Define What Type of Tade Ae you? Boke Nightmae srs Tend Ride By Vladimi Ribakov Ceato of Pips Caie 20 of June 2010 1 Disclaime and Risk Wanings Tading any financial maket involves isk. The content of this
More informationPlease Provide Your Medica re Insurance Inform ation
ld] Please check which plan you w ant to enroll in: ct ABC $XX per month Product XYZ $XX per month Application for 65 + Medicare Supplement Insurance for Individuals FIRST Name: Middle Initial Mr. Mrs.
More informationDatabase Management Systems
Contents Database Management Systems (COP 5725) D. Makus Schneide Depatment of Compute & Infomation Science & Engineeing (CISE) Database Systems Reseach & Development Cente Couse Syllabus 1 Sping 2012
More information883 Brochure A5 GENE ss vernis.indd 1-2
ess x a eu / u e a. p o.eu c e / :/ http EURAXESS Reseaches in Motion is the gateway to attactive eseach caees in Euope and to a pool of wold-class eseach talent. By suppoting the mobility of eseaches,
More informationApplication Submission Checklist To Mutual of Omaha For Medicare Supplement Coverage MO, ND
P.O. Box 3608 Omaha, Nebraska 68103-3608 Application Submission Checklist To Mutual of Omaha For Medicare Supplement Coverage MO, ND THIS APPLICATION MUST BE USED TO WRITE MUTUAL OF OMAHA MEDICARE SUPPLEMENT
More informationThank you for your interest in the KPS Health Plans Medicare Supplement plan!
Thank you for your interest in the KPS Health Plans Medicare Supplement plan! Below is a link to the policy outline and attached is a printable copy of the Medicare Supplement Enrollment Form. Should you
More informationINITIAL MARGIN CALCULATION ON DERIVATIVE MARKETS OPTION VALUATION FORMULAS
INITIAL MARGIN CALCULATION ON DERIVATIVE MARKETS OPTION VALUATION FORMULAS Vesion:.0 Date: June 0 Disclaime This document is solely intended as infomation fo cleaing membes and othes who ae inteested in
More informationMEDICARE SUPPLEMENT APPLICATION - NEVADA Please complete entire application.
MEDICARE SUPPLEMENT APPLICATION - NEVADA Please complete entire application. Select a plan: Plan A Plan B Plan F Plan I Plan J Section 1 Applicant Information This complete original application will be
More informationYOUR REPRODUCTIVE LIFE PLANNING GUIDE
YOUR REPRODUCTIVE LIFE PLANNING GUIDE Notheast Floida Healthy Stat Coalition 644 Cesey Blvd., Suite 210, Jacksonville, FL 32211 p. 904.723.5422 / f. 904.723.5433 www.nefhealthystat.og KEY QUESTIONS TO
More informationEnrollment Application
Enrollment Application Information About You 840 Carolina Street Sauk City, Wisconsin 53583-1374 (800) 926-8227; Fax (608) 836-0092 www.unityhealth.com Effective Date: / / Name (Last, First, Middle Initial):
More informationConfirmation of Booking
The Pesentes Rebecca Mogan Rebecca is a Taxation Consultant with the NTAA and has ove 15 yeas tax expeience. Rebecca holds a Bachelo of Ats and Law and a Mastes of Taxation. Rebecca has pesented a numbe
More informationP.O. Box 91120, MS 295 Seattle, WA 98111-9220 1-800-290-1278 Fax: 425-918-5278
Oregon Medicare Supplement Enrollment Application for Plans A, F, High Deductible F and N P.O. Box 91120, MS 295 Seattle, WA 98111-9220 1-800-290-1278 Fax: 425-918-5278 You are eligible to apply for a
More informationBlueCross BlueShield of Western New York. Application for Medicare Supplement Insurance
BlueCross BlueShield of Western New York Application for Medicare Supplement Insurance (Plan A, Plan B, Plan C, Plan F, High Deductible Plan F, Plan M and Plan N) The sale of a Medicare Supplement policy
More informationApplication for Medicare Supplement Insurance Plan PART ONE. Section B. Personal Information. Instructions
Application for Medicare Supplement Insurance Plan Instructions Complete this application in ink and sign on the appropriate line in PART THREE. To be considered for coverage, you must be age 65 or over,
More informationOffice of Family Assistance. Evaluation Resource Guide for Responsible Fatherhood Programs
Office of Family Assistance Evaluation Resouce Guide fo Responsible Fathehood Pogams Contents Intoduction........................................................ 4 Backgound..........................................................
More informationVAT201. efiling user guide for Value-Added Tax
efiling use guide fo Value-Added Tax CONTENTS 1. INTODUCTION...2 2. EGISTEING FO VAT...2 3. EQUESTING VENDO DECLAATION...5 4. COMPLETING THE VENDO DECLAATION...8 5. SUBMITTING THE DECLAATION FO A SPECIFIC
More informationHealth First Insurance, Inc. Medicare Supplement Application 2013
6450 US Highway 1, Rockledge, FL 32955 Customer Service: 321.434.4822 Toll-free 1.855.443.4735 TTY relay 1.800.955.8771 Monday through Friday from 8 am to 8 pm, Saturday from 8 am to noon A. General Information
More informationN Basic, including 100% Part B coinsurance. Basic including 100% Part B coinsurance* Basic including 100% Part B coinsurance
HEARTLAND NATIONAL LIFE INSURANCE COMPANY Outline of Medicare Supplement Coverage Benefit Plans A, D, F, G, M and N Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After Jun 1,
More informationApplication for Medicare Supplement Insurance Plan
Application for Medicare Supplement Insurance Plan Instructions Complete this application in ink and sign on the appropriate line in PART THREE. To be considered for coverage, you must be age 65 or over,
More informationAshfield Girls High School. Critical Incident Policy
Ashfield Gils High School A Specialist School fo ICT Citical Incident Policy Citical Incident Policy 2 Citical Incident Policy A Specialist School fo ICT Ashfield Gils High School CRITICAL INCIDENT POLICY
More informationKNIGHTS OF COLUMBUS LEADERSHIP RESOURCES. Practical Information for Grand Knights, District Deputies and Financial Secretaries
KNIGHTS OF COLUMBUS LEADERSHIP RESOURCES Pactical Infomation fo Gand Knights, Distict Deputies and Financial Secetaies Thank you fo taking on the esponsibility of being a leade in the Knights of Columbus.
More informationAetna Individual Medicare Supplement Plan Application Aetna Life Insurance Company PO Box 13547, Pensacola, FL 32591-3547
Aetna Individual Medicare Supplement Plan Application Aetna Life Insurance Company PO Box 13547, Pensacola, FL 32591-3547 INSTRUCTIONS: To be considered complete, all sections on this form must be filled
More informationPBT MediCap Medicare Supplement Plans Enrollment Form
PBT MediCap Medicare Supplement Plans Enrollment Form Complete this enrollment form if you or your spouse is over age 65 or if medically disabled. ISMS and CMS members call 1-800-621-0748 ISDS members
More informationTowards Automatic Update of Access Control Policy
Towads Automatic Update of Access Contol Policy Jinwei Hu, Yan Zhang, and Ruixuan Li Intelligent Systems Laboatoy, School of Computing and Mathematics Univesity of Westen Sydney, Sydney 1797, Austalia
More informationOffice Leasing Guide WHAT YOU NEED TO KNOW BEFORE YOU SIGN. Colliers International Office Leasing Guide P. 1
Office Leasing Guide WHAT YOU NEED TO KNOW BEFORE YOU SIGN Collies Intenational Office Leasing Guide P. 1 THE OFFICE LEASING GUIDE This step-by-step guide has been assembled to eflect Collies Intenational
More informationHealth Net life insurance company Application for a
Health Net life insurance company Application for a Medicare Supplement Policy Office use only: Approval Date: Effective Date: Plan/Group ID: Guarantee Issue: ABD Included: Yes No Please follow these application
More informationBOARD OF EDUCATION Ossining Union Free School District Ossining, NY. Work Session/Special Meeting March 4, 2015 MINUTES
BOARD OF EDUCATION Ossining Union Fee School Distict Ossining, NY Wok Session/Special Meeting Mach 4, 2015 Ossining High School Libay Special Meeting: 7:00 p.m. MINUTES Pesent: Bill Kess, Boad Pesident,
More informationMEDIAKit NVITATIONAL. theleague.coop/sponsors. 18 th Annual
theleague.coop/sponsos 18 th Annual NVITATIONAL Ou Membes The Wisconsin Cedit Union League is the state s only tade association fo cedit unions in Wisconsin. Of the 149 cedit unions in Wisconsin 142 of
More informationTHP Insurance Company, Inc. (THP) Medicare Supplement Insurance Policy Application Ohio and West Virginia
Important Notice: Refer to the Guaranteed Issue Guide to determine eligibility for automatic acceptance. If eligible, indicate which situation is applicable in the Guaranteed Issue section. You are not
More informationHow To Find The Optimal Stategy For Buying Life Insuance
Life Insuance Puchasing to Reach a Bequest Ehan Bayakta Depatment of Mathematics, Univesity of Michigan Ann Abo, Michigan, USA, 48109 S. David Pomislow Depatment of Mathematics, Yok Univesity Toonto, Ontaio,
More informationApplication for Medicare Supplement Coverage
Application for Medicare Supplement Coverage Complete application in full Use ballpoint pen Print legibly Plan Selection Plan A Plan D Plan N Requested Effective Plan C Plan F Date: / / Applicant Information
More informationSCP Material ID: 2014_MedSupp_Application. Medicare Supplement Application
Medicare Supplement Application OPEN ENROLLMENT AND GUARANTEED ISSUE PERIOD If any of the following situations apply, applicant is in an open enrollment or guaranteed issue period. ELIGIBILITY FOR OPEN
More informationThe force between electric charges. Comparing gravity and the interaction between charges. Coulomb s Law. Forces between two charges
The foce between electic chages Coulomb s Law Two chaged objects, of chage q and Q, sepaated by a distance, exet a foce on one anothe. The magnitude of this foce is given by: kqq Coulomb s Law: F whee
More informationThe Binomial Distribution
The Binomial Distibution A. It would be vey tedious if, evey time we had a slightly diffeent poblem, we had to detemine the pobability distibutions fom scatch. Luckily, thee ae enough similaities between
More informationDo Vibrations Make Sound?
Do Vibations Make Sound? Gade 1: Sound Pobe Aligned with National Standads oveview Students will lean about sound and vibations. This activity will allow students to see and hea how vibations do in fact
More informationLeft- and Right-Brain Preferences Profile
Left- and Right-Bain Pefeences Pofile God gave man a total bain, and He expects us to pesent both sides of ou bains back to Him so that He can use them unde the diection of His Holy Spiit as He so desies
More informationApplication for Senior Medicare Supplement Plans BLUE CROSS AND BLUE SHIELD OF MONTANA P.O. BOX 4309 HELENA, MT 59604
Application for Senior Medicare Supplement Plans BLUE CROSS AND BLUE SHIELD OF MONTANA P.O. BOX 4309 HELENA, MT 59604 SENIORAPP062010 FLD New Enrollment Change Benefit Plan (e.g., Plan F to Plan C) Transfer
More informationNOVEMBER 8-10, 2013 PREVIEW NIGHT: NOVEMBER 7 MARKET HALL
DALLAS SAMPLE SALE NOVEMBER 8-10, 2013 PREVIEW NIGHT: NOVEMBER 7 MARKET HALL EXHIBITOR GENERAL INFORMATION Dallas Sample Sale is a campus-wide event located at Main Hall of Dallas Maket Hall. The event
More informationAMB111F Financial Maths Notes
AMB111F Financial Maths Notes Compound Inteest and Depeciation Compound Inteest: Inteest computed on the cuent amount that inceases at egula intevals. Simple inteest: Inteest computed on the oiginal fixed
More informationCalculating the. True Costs of. Pest Control. Department of Ecology Hazardous Waste and Toxics Reduction Program Publication Number 99-433
Calculating the Tue Costs of Pest Contol Depatment of Ecology Hazadous Waste and Toxics Reduction Pogam Publication Numbe 99-433 Fo a copy of this document, please contact: Depatment of Ecology Publications
More informationAPPLICATION FOR MEDICARE SUPPLEMENT INSURANCE
301 S. Vine St. Urbana, IL 61801-3347 Member Assigned #: 1-800-965-4022 TTY/TDD 711 or Effective Date: 1-800-526-0844 (Illinois Relay) APPLICATION FOR MEDICARE SUPPLEMENT INSURANCE SECTION 1: APPLICANT(S)
More informationThe Supply of Loanable Funds: A Comment on the Misconception and Its Implications
JOURNL OF ECONOMICS ND FINNCE EDUCTION Volume 7 Numbe 2 Winte 2008 39 The Supply of Loanable Funds: Comment on the Misconception and Its Implications. Wahhab Khandke and mena Khandke* STRCT Recently Fields-Hat
More information2. APPLICANT S NAME, HOME ADDRESS AND APPLICANT S MAILING ADDRESS (If different from your home address.)
AGENT & OFFICE USE ONLY Date Received: Group Number: Effective Date: Agent Number: Agency Number: APPLICATION FOR MEDICARE SUPPLEMENT PROGRAM MEDIGAP BLUE 1. ELIGIBILITY If you are not eligible for Medicare
More informationOver-encryption: Management of Access Control Evolution on Outsourced Data
Ove-encyption: Management of Access Contol Evolution on Outsouced Data Sabina De Capitani di Vimecati DTI - Univesità di Milano 26013 Cema - Italy decapita@dti.unimi.it Stefano Paaboschi DIIMM - Univesità
More informationHow to create RAID 1 mirroring with a hard disk that already has data or an operating system on it
AnswesThatWok TM How to set up a RAID1 mio with a dive which aleady has Windows installed How to ceate RAID 1 mioing with a had disk that aleady has data o an opeating system on it Date Company PC / Seve
More informationThe LCOE is defined as the energy price ($ per unit of energy output) for which the Net Present Value of the investment is zero.
Poject Decision Metics: Levelized Cost of Enegy (LCOE) Let s etun to ou wind powe and natual gas powe plant example fom ealie in this lesson. Suppose that both powe plants wee selling electicity into the
More informationIndividual Medicare supplement application
Individual Medicare supplement application Please mail your completed application to: Moda Health Plan, Inc., Attn: Medicare Billing & Eligibility, PO Box 40384, Portland, OR 97240-0384 phone 503-265-4762
More informationExperts Share Their Insights to Grow Your Group
AMERICAN ACADEMY OF DENTAL GROUP PRACTICE ANNUAL CONFERENCE & EXHIBITION Expets Shae Thei Insights to Gow You Goup MIRAGE LAS VEGAS FEBRUARY 11-14, 2015 BE PART OF DENTISTRY S ANNUAL GROUP PRACTICE EVENT
More informationModule Availability at Regent s School of Drama, Film and Media Autumn 2016 and Spring 2017 *subject to change*
Availability at Regent s School of Dama, Film and Media Autumn 2016 and Sping 2017 *subject to change* 1. Choose you modules caefully You must discuss the module options available with you academic adviso/
More informationTransmittal 46 Date: JANUARY 27, 2006. SUBJECT: Cardiac Catheterization Performed in Other Than a Hospital Setting
anual ystem Pub 100-03 edicae National oveage Deteminations Depatment of ealth & uman evices (D) entes fo edicae & edicaid evices () Tansmittal 46 Date: JANUAY 27, 2006 hange equest 4280 UBJET: adiac atheteization
More informationThere is considerable variation in health care utilization and spending. Geographic Variation in Health Care: The Role of Private Markets
TOMAS J. PHILIPSON Univesity of Chicago SETH A. SEABUY AND Copoation LEE M. LOCKWOOD Univesity of Chicago DANA P. GOLDMAN Univesity of Southen Califonia DAIUS N. LAKDAWALLA Univesity of Southen Califonia
More informationMedicare Select Application Underwritten and Adminstered by MercyCare HMO, Inc.
Medicare Select Application Underwritten and Adminstered by MercyCare HMO, Inc. LIVE WELL. WE LL INSURE YOU DO. MERCYCARE HMO, INC. Contact us 800.895.2421 plans for everyone. individuals >> seniors >>
More informationFrom PLI s Treatise Initial Public Offerings: A Practical Guide to Going Public #19784 PREPACKAGED BANKRUPTCY AND PREARRANGED BANKRUPTCY PROCESS
Fom PLI s Teatise Initial Public Offeings: A Pactical Guide to Going Public #19784 16 PREPACKAGED BANKRUPTCY AND PREARRANGED BANKRUPTCY PROCESS Deyck Palme Jessica Fink Cadwalade, Wickesham & Taft LLP
More informationChris J. Skinner The probability of identification: applying ideas from forensic statistics to disclosure risk assessment
Chis J. Skinne The pobability of identification: applying ideas fom foensic statistics to disclosue isk assessment Aticle (Accepted vesion) (Refeeed) Oiginal citation: Skinne, Chis J. (2007) The pobability
More informationHow to recover your Exchange 2003/2007 mailboxes and emails if all you have available are your PRIV1.EDB and PRIV1.STM Information Store database
AnswesThatWok TM Recoveing Emails and Mailboxes fom a PRIV1.EDB Exchange 2003 IS database How to ecove you Exchange 2003/2007 mailboxes and emails if all you have available ae you PRIV1.EDB and PRIV1.STM
More information