INSTRUCTIONS: ALABAMA REQUEST FOR REIMBURSEMENT PREFERRED HEALTH FSA/HRA (Form CL-472)

In Alabama, state employees enrolled with BlueCross BlueShield use a form CL-472 to request a reimbursement for eligible health services. This document can be obtained from the website maintained by BlueCross BlueShield of Alabama.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 1: The employee should enter their signature and the date at the top of the form where indicated.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 2: Section 1 concerns the employee. Your first name, middle initial and last name in the first three blank boxes.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 3: In the next three blank boxes, enter the month, date and year of your birth.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 4: Enter your preferred blue account number prefix in the next blank box.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 5: Enter your preferred blue account number contract number in the blank box.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 6: Enter your company name in the next blank box.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 7: Enter your work and home phone numbers in the next two blank boxes, including the area codes.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 8: Section 2 concerns the type of reimbursement being sought. Indicate whether the service was medical, vision, dental, orthodontics, RX/OTC or other by filling in the oval next to the appropriate statement.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 9: In the first two blank boxes, enter the patient's first and last names.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 10: Indicate whether the patient is self, your spouse or a dependent by filling in the appropriate oval.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 11: Indicate whether the patient is covered by insurance by filling in the appropriate oval.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 12: Provide all other information requested about the patient. You may document up to five patients on one form. Provide the amount requested for reimbursement for each service and the total at the bottom of the page.

INSTRUCTIONS: CONNECTICUT LICENSE CANCEL/TERMINATION FORM

To request that a Connecticut license related to insurance be cancelled, use the form discussed in this article. This document can be obtained from the website maintained by the government of Connecticut.

Connecticut License Cancel/Termination Form Step 1: Enter your Connecticut license number on the first blank line or your National Producer Number (NPN) on the second blank line.

Connecticut License Cancel/Termination Form Step 2: Enter the first, middle and last name of the licensee on the third blank line.

Connecticut License Cancel/Termination Form Step 3: Enter the last four digits of the Social Security number of the licensee on the fourth blank line.

Connecticut License Cancel/Termination Form Step 4: Enter the license type on the fifth blank line.

Connecticut License Cancel/Termination Form Step 5: Enter the name of the business entity on the sixth blank line.

Connecticut License Cancel/Termination Form Step 6: Enter the federal employer identification number of the business entity on the seventh blank line.

Connecticut License Cancel/Termination Form Step 7: Indicate with a check mark whether you wish for termination of this license to take place immediately or on the license expiration date.

Connecticut License Cancel/Termination Form Step 8: Write the reason for the requested termination where indicated.

Connecticut License Cancel/Termination Form Step 9: Question 1 requires you to indicate whether you currently have any complaints or actions which are pending, active or recently deposed filed against you by any state's insurance department by circling "yes" or "no." If yes, provide a written explanation.

Connecticut License Cancel/Termination Form Step 10: Question 2 requires you to indicate whether you currently have any complaints or actions which are pending, actively or recently deposed filed against you by the Financial Industry Regulatory Authority (FINRA) by circling "yes" or "no." If yes, provide a written explanation.

Connecticut License Cancel/Termination Form Step 11: Question 3 requires you to indicate whether any insurance company has terminated your appointment with them in the last 6 months by circling "yes" or "no." If yes, write the reason.

Connecticut License Cancel/Termination Form Step 12: Provide the name, phone number and email address of a contact person.

Connecticut License Cancel/Termination Form Step 13: The licensee should sign and date the form.

INSTRUCTIONS: CONNECTICUT EXEMPTION CLAIM FORM FINANCIAL INSTITUTION EXECUTION (Form JD-CV-24A)

When a financial institution receives a Connecticut form JD-CV-24N requiring them to withhold moneys owed by a member who is a debtor, they may file a form JD-CV-24A if they are exempt from this order. This document can be obtained from the website of the Connecticut Judicial Branch.

Connecticut Exemption Claim Form Financial Institution Execution JD-CV-24A Step 1: Section I is to be completed by the plaintiff creditor. Indicate whether the case was processed by judicial district, housing sessions or geographical area court. If the latter, enter its number. 

Connecticut Exemption Claim Form Financial Institution Execution JD-CV-24A Step 2: Enter the name and address of the court.

Connecticut Exemption Claim Form Financial Institution Execution JD-CV-24A Step 3: Enter the name of the case.

Connecticut Exemption Claim Form Financial Institution Execution JD-CV-24A Step 4: Enter the name of the judgment debtor.

Connecticut Exemption Claim Form Financial Institution Execution JD-CV-24A Step 5: Enter the docket number.

Connecticut Exemption Claim Form Financial Institution Execution JD-CV-24A Step 6: Section II is to be completed by the financial institution. Enter the name and address of the financial institution to which the exemption claim should be returned.

Connecticut Exemption Claim Form Financial Institution Execution JD-CV-24A Step 7: Enter the date of mailing to the judgment debtor.

Connecticut Exemption Claim Form Financial Institution Execution JD-CV-24A Step 8: Enter the last four digits of all of the debtor's account numbers.

Connecticut Exemption Claim Form Financial Institution Execution JD-CV-24A Step 9: Enter the amount removed pursuant to execution.

Connecticut Exemption Claim Form Financial Institution Execution JD-CV-24A Step 10: Enter the amount and type of readily identifiable funds not removed.

Connecticut Exemption Claim Form Financial Institution Execution JD-CV-24A Step 11: Section IV requires the financial institution to indicate the basis for the claimed execution by checking the box next to the applicable statement.

Connecticut Exemption Claim Form Financial Institution Execution JD-CV-24A Step 12: If the amount claimed to be exempt is less than the entire amount, enter it where indicated.

Connecticut Exemption Claim Form Financial Institution Execution JD-CV-24A Step 13: An authorized representative of the institution should sign and date the form, as well as providing a contact telephone number, and the complete mailing address of the debtor. This should be done before a notary public or a commissioner of the Superior Court.

INSTRUCTIONS: CONNECTICUT APPLICATION FOR ISSUANCE OF SUBPOENA (Form JD-CV-62)

When a self-represented applicant has been convicted of a family violence crime or a crime of risk of injury to children, sexual assault or stalking, they may use a form JD-CV-62 to request that one or more of the victims be issued a subpoena. This document can be found on the website of the Connecticut Judicial Branch.

Connecticut Application For Issuance Of Subpoena JD-CV-62 Step 1: Indicate whether your case is being heard in a judicial district, housing session or geographical area with a check mark.

Connecticut Application For Issuance Of Subpoena JD-CV-62 Step 2: Enter the location in which your case is being processed in the first blank box.

Connecticut Application For Issuance Of Subpoena JD-CV-62 Step 3: Enter your docket number in the next blank box.

Connecticut Application For Issuance Of Subpoena JD-CV-62 Step 4: Enter the name of the case in the next blank box.

Connecticut Application For Issuance Of Subpoena JD-CV-62 Step 5: Indicate with a check mark whether this is a civil, housing, family or family support magistrate case.

Connecticut Application For Issuance Of Subpoena JD-CV-62 Step 6: Indicate with a check mark whether you have been convicted of any of the crimes listed in the introductory paragraph of this article. If "yes," indicate with a check mark whether you are asking to subpoena the victim of your crime.

Connecticut Application For Issuance Of Subpoena JD-CV-62 Step 7: The next section requires you to detail the person to whom you are requesting a subpoena be issued. You may list up to two people. For each, enter their name and street address, the reason you believe testimony from this person is necessary, and the items you wish for them to be ordered to bring to court.

Connecticut Application For Issuance Of Subpoena JD-CV-62 Step 8: In the next section, place an X next to all proceedings you are requesting a subpoena form. Check the first line if this is for a trial and enter the date, the judge (if known), and the date for which the pre-trial hearing is scheduled. Place an X on the second line if this concerns a short calendar matter. Enter the date the hearing is scheduled for and the presiding judge, magistrate or hearing officer if known. The last line concerns family support magistrate hearings.

INSTRUCTIONS: CONNECTICUT REQUEST FOR ADJUDICATION OF DISCOVERY OR DEPOSITION DISPUTE UNDER STATEWIDE STANDING ORDER (Form JD-CV-119)

To request adjudication for a discovery or deposition dispute in Connecticut, a form JC-DV-119 should be filed. This document can be obtained from the website maintained by the Judicial Branch of the State of Connecticut.

Connecticut Request For Adjudication Of Discovery Or Deposition Dispute Under Statewide Standing Order JD-CV-119 Step 1: In the first blank box, enter the name of the judicial district.

Connecticut Request For Adjudication Of Discovery Or Deposition Dispute Under Statewide Standing Order JD-CV-119 Step 2: In the second blank box, enter the name of the case.

Connecticut Request For Adjudication Of Discovery Or Deposition Dispute Under Statewide Standing Order JD-CV-119 Step 3: In the third blank box, enter the docket number.

Connecticut Request For Adjudication Of Discovery Or Deposition Dispute Under Statewide Standing Order JD-CV-119 Step 4: In the fourth blank box, print the name of the party filing this request. 

Connecticut Request For Adjudication Of Discovery Or Deposition Dispute Under Statewide Standing Order JD-CV-119 Step 5: In the fifth blank box, indicate with a check mark whether this request concerns a deposition dispute or a discovery dispute.

Connecticut Request For Adjudication Of Discovery Or Deposition Dispute Under Statewide Standing Order JD-CV-119 Step 6: In the sixth blank box, give the trial date.

Connecticut Request For Adjudication Of Discovery Or Deposition Dispute Under Statewide Standing Order JD-CV-119 Step 7: If you are filing regarding a discovery dispute, specify the motion or objection numbers and titles to be decided in Section 1, along with any related motion or objection numbers and titles.

Connecticut Request For Adjudication Of Discovery Or Deposition Dispute Under Statewide Standing Order JD-CV-119 Step 8: If you are filing regarding a deposition dispute, specify the motion or objection numbers and titles to be decided in Section 2, along with any related motion or objection numbers and titles.

Connecticut Request For Adjudication Of Discovery Or Deposition Dispute Under Statewide Standing Order JD-CV-119 Step 9: Indicate with a check mark whether or not you are requesting a telephone conference. This only applies to deposition disputes.

Connecticut Request For Adjudication Of Discovery Or Deposition Dispute Under Statewide Standing Order JD-CV-119 Step 10: Complete Section 3 before a notary public or assistant clerk of the Superior Court.