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Form C Supplemental Claim Form

Form C Supplemental Claim Form

 

INSTRUCTIONS: ALABAMA SUPPLEMENTAL CLAIM (Form C)

 

 

The form discussed in this article is used to file a claim for expenses not paid by an Alabama public department or agency. This document can be obtained from the website of the Alabama State Board of Adjustment. 

 

Alabama Supplemental Claim C Step 1: If this form is a supplement to a previously filed claim, enter the claim number and agency name where indicated.

 

Alabama Supplemental Claim C Step 2: Section 1 concerns the claimant. On the first two blank lines, enter the name and mailing address of the claimant.

 

Alabama Supplemental Claim C Step 3: On the third blank line, enter your home phone number, including the area code.

 

Alabama Supplemental Claim C Step 4: On the fourth blank line, enter your business phone number, including the area code.

 

Alabama Supplemental Claim C Step 5: On the fifth blank line, enter your Social Security number or federal ID number.

 

Alabama Supplemental Claim C Step 6: If the injured party is 19 years of age or younger, their parent or guardian must file the form as the claimant. If this is the case, enter the name and age of the minor on the sixth blank line and the name and relationship of the person with whom the minor lives.

 

Alabama Supplemental Claim C Step 7: Section 2 concerns the claimant's attorney, if applicable. Enter the attorney's name on the first blank line, their mailing address on the second blank line, and their zip code and telephone number on the last two blank lines.

 

Alabama Supplemental Claim C Step 8: In section 3A, indicate whether this is a claim for uninsured medical expenses with a check mark. If so, enter the amount. Indicate whether you have insurance with a check mark. If so, enter the name of the company.

 

Alabama Supplemental Claim C Step 9: In section 3B, indicate whether this claim concerns a permanent disability with a check mark. If so, provide all information requested.

 

Alabama Supplemental Claim C Step 10: In section 3C, indicate whether this claim concerns lost wages or compensation for leave used with a check mark. If so, provide all information requested. In section 3D, indicate whether this claim concerns miscellaneous or other expenses with a check mark. If so, provide all information requested. Sign the form and have it certified by a notary public.

 

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Form B Death Benefit Claim Form

Form B Death Benefit Claim Form

 

INSTRUCTIONS: ALABAMA DEATH BENEFIT CLAIM FORM (Form B)

 

 

As part of the death benefit claim process for survivors of Alabama peace officer or fireman who have had their claim denied, a form B will be filed. This document can be obtained from the website maintained by the Alabama Board of Adjustment.

 

Alabama Death Benefit Claim Form B Step 1: Enter your name on the first blank line.

 

Alabama Death Benefit Claim Form B Step 2: On the first three blank lines of line 1, enter your name, mailing address and zip code.

 

Alabama Death Benefit Claim Form B Step 3: On the next blank line of line 1, enter your home telephone number, including the area code.

 

Alabama Death Benefit Claim Form B Step 4: On the next blank line of line 1, enter your work telephone number, including the area code.

 

Alabama Death Benefit Claim Form B Step 5: On line 2, enter the date of death of the peace officer or fireman.

 

Alabama Death Benefit Claim Form B Step 6: On line 3, enter how long the peace officer or fireman had been employed in that capacity.

 

Alabama Death Benefit Claim Form B Step 7: Line 4 states that you must attach a death certificate and affidavit from the head of the agency which employed the deceased stating the status of their employment and the circumstances of their death.

 

Alabama Death Benefit Claim Form B Step 8: In section 5, you must document all surviving dependents in the table provided. In the first column, enter the full name and address of each dependent.

 

Alabama Death Benefit Claim Form B Step 9: In the second column, enter each dependent's relationship to the deceased.

 

Alabama Death Benefit Claim Form B Step 10: In the third column, enter each dependent's age.

 

Alabama Death Benefit Claim Form B Step 11: In the fourth column, indicate whether the deceased was contributing to support each listed dependent.

 

Alabama Death Benefit Claim Form B Step 12: On line 6, enter the geographic location of the injury or death.

 

Alabama Death Benefit Claim Form B Step 13: On line 7, state in your own words the circumstances related to the death of the peace officer or fireman.

 

Alabama Death Benefit Claim Form B Step 14: Sign the form where indicated, then have it certified by a notary public.

 

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Instructions for Filing Death Benefit Claims

 

INSTRUCTIONS: ALABAMA DEATH BENEFIT CLAIMS EXAMPLES OF SUPPORTING DOCUMENTATION

 

 

This article discusses an information document outlining acceptable supporting documentation for support claims due to the death of an Alabama peace officer or fireman. This document can be obtained from the website maintained by the Alabama State Board of Adjustment.

 

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 1: The first listed acceptable supporting document is a death certificate for the deceased Alabama peace officer or fireman.

 

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 2: The second listed acceptable supporting document is an accident or incident report, if applicable.

 

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 3: The third listed acceptable support document is an affidavit from the head of the employing agency or department which must answer several questions about the death of the peace officer or fireman. The first question which must be addressed in this affidavit is if the peace officer or fireman was engaged in the performance of their duties when killed or receiving injuries contributing to their death.

 

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 4: The second question to be answered in this affidavit is if the peace officer or fireman was engaged in willful misconduct.

 

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 5: The third question to be answered is if the peace officer or fireman was intoxicated by alcohol or drugs at the time of death and whether tests were conducted with regard to alcohol or drugs.

 

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 6: The fourth question to be answered is if the peace officer or fireman failed to use safety appliances supplied by their employer.

 

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 7: The fifth question to be answered is if the peace officer or fireman refused or neglected to perform a statutory duty.

 

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 8: The sixth question to be answered is if the peace officer or fireman violated a law or willfully breached a reasonable rule or regulation governing the performance of their duties or employment.

 

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 9: The rest of the form identifies documents acceptable for identifying surviving dependents. 

 

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CT Surety Liquidation Claim Form

CT Surety Liquidation Claim Form

 

INSTRUCTIONS: CONNECTICUT PROOF OF CLAIM (SURETY LIQUIDATION)

 

 

This article discusses a proof of claim form that was made available following the liquidation of the Connecticut Surety Corporation and related affiliates. This form was made available to file a claim against these businesses. Though the deadline to file this form was August 29, 2003, the form can still be found on the website of the government of Connecticut.

 

Connecticut Proof Of Claim (Surety Liquidation) Step 1: Enter the claimant name in the first blank box.

 

Connecticut Proof Of Claim (Surety Liquidation) Step 2: Enter the claimant address in the second blank box.

 

Connecticut Proof Of Claim (Surety Liquidation) Step 3: Enter the claimant telephone number in the third blank box.

 

Connecticut Proof Of Claim (Surety Liquidation) Step 4: Enter the claimant Social Security number or tax identification number in the fourth blank box.

 

Connecticut Proof Of Claim (Surety Liquidation) Step 5: Enter the total amount of the claim in the fifth blank box.

 

Connecticut Proof Of Claim (Surety Liquidation) Step 6: If any affiliates paid any portion of your claim, enter the name of the affiliate in the sixth blank box and the date of payment and the amount of payment made in the seventh blank box.

 

Connecticut Proof Of Claim (Surety Liquidation) Step 7: If you hold any security or collateral provided by the affiliates or claim a right of setoff against any of the affiliates, enter the name of the affiliates in question in the eighth blank box and the amount held or subject to set setoff in the ninth blank box.

 

Connecticut Proof Of Claim (Surety Liquidation) Step 8: If you assert any right of priority senior to the right of general creditors, identify the priority asserted and the basis for this assertion in the tenth blank box.

 

Connecticut Proof Of Claim (Surety Liquidation) Step 9: If you are represented by an attorney, enter their name in the eleventh blank box, their address in the twelfth blank box, and their telephone number in the thirteen blank box.

 

Connecticut Proof Of Claim (Surety Liquidation) Step 10: The claimant or individual, partner, officer or legal representative of the claimant should provide their signature, the date, their title or official capacity and telephone number where indicated. 

 

Connecticut Proof Of Claim (Surety Liquidation) Step 11: A notary public should be presented with the form to affix their seal.

 

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Southland Benefit Solutions Injury or Sickness Insurance Claim

Southland Benefit Solutions Injury or Sickness Insurance Claim

 

INSTRUCTIONS: ALABAMA SOUTHLAND BENEFIT SOLUTIONS EMPLOYEE'S STATEMENT

 

 

Alabama state employees enrolled in medical coverage administered by Southland Benefit Solutions can use the form discussed in this article to file a claim for a hospital bill. This document can be obtained from the website maintained by Southland Benefit Solutions.

 

Alabama Southland Benefit Solutions Employee's Statement Step 1: Enter the subscriber's name in box 1.

 

Alabama Southland Benefit Solutions Employee's Statement Step 2: Enter the subscriber's contract number in box 2.

 

Alabama Southland Benefit Solutions Employee's Statement Step 3: Enter the subscriber's home address in box 3.

 

Alabama Southland Benefit Solutions Employee's Statement Step 4: Enter the patient's name in box 4.

 

Alabama Southland Benefit Solutions Employee's Statement Step 5: Enter the patient's date of birth in box 5.

 

Alabama Southland Benefit Solutions Employee's Statement Step 6: Enter the patient's age in box 6.

 

Alabama Southland Benefit Solutions Employee's Statement Step 7: Indicate the patient's sex with a check mark in box 7.

 

Alabama Southland Benefit Solutions Employee's Statement Step 8: Indicate the patient's relationship to the subscriber with a check mark in box 8.

 

Alabama Southland Benefit Solutions Employee's Statement Step 9: Enter the subscriber's home and work phone number in box 9.

 

Alabama Southland Benefit Solutions Employee's Statement Step 10: In box 10, enter the type of illness or injury or the doctor's diagnosis.

 

Alabama Southland Benefit Solutions Employee's Statement Step 11: In the next blank box, enter the physician's name and address.

 

Alabama Southland Benefit Solutions Employee's Statement Step 12: In the next blank box, enter the name of the hospital, if confined.

 

Alabama Southland Benefit Solutions Employee's Statement Step 13: In the next blank box, enter the date you were admitted.

 

Alabama Southland Benefit Solutions Employee's Statement Step 14: In the next blank box, enter the date you were discharged.

 

Alabama Southland Benefit Solutions Employee's Statement Step 15: In the next blank box, enter the date the accident or sickness began.

 

Alabama Southland Benefit Solutions Employee's Statement Step 16: In the next blank box, enter the date the accident or sickness was first treated.

 

Alabama Southland Benefit Solutions Employee's Statement Step 17: In the next blank box, indicate whether the condition was related to accident or illness.

 

Alabama Southland Benefit Solutions Employee's Statement Step 18: Sign and date the form where indicated.

 

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