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. 

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.

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.