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Form B-215 Special Mobile Equipment Affidavit

Form B-215 Special Mobile Equipment Affidavit

 

INSTRUCTIONS: CONNECTICUT SPECIAL MOBILE EQUIPMENT AFFIDAVIT (Form B-215)

 

 

To attest to the safety of safety mobile equipment or a special mobile agricultural vehicle to be used in Connecticut, use a form B-215. This affidavit can be obtained from the website maintained by the government of the state of Connecticut.

 

Connecticut Special Mobile Equipment Affidavit B-215 Step 1: Enter the vehicle make in the first blank box.

 

Connecticut Special Mobile Equipment Affidavit B-215 Step 2: Enter the vehicle body style in the second blank box.

 

Connecticut Special Mobile Equipment Affidavit B-215 Step 3: Enter the vehicle identification number in the third blank box.

 

Connecticut Special Mobile Equipment Affidavit B-215 Step 4: Enter the vehicle registration number in the fourth blank box.

 

Connecticut Special Mobile Equipment Affidavit B-215 Step 5: Enter the name of the applicant in the fifth blank box.

 

Connecticut Special Mobile Equipment Affidavit B-215 Step 6: Enter the full street address, city, state and zip code of the applicant in the sixth blank box.

 

Connecticut Special Mobile Equipment Affidavit B-215 Step 7: Check the box next to "special mobile equipment" if this is the type of vehicle being documented. By doing so, you are agreeing with the paragraph printed in this section, which states that the vehicle can be safely operated on Connecticut highways, and that you agree not to operate this vehicle on any highway half an hour after sunset or half an hour before sunrise, as well as under any other inadequate light conditions. This paragraph also states that the vehicle will only be driven from its place of storage to the construction site or from one site to another, and that it will not be used to transport passengers or payload on the highway unless working on a highway construction project or a project requiring crossing the highway.

 

Connecticut Special Mobile Equipment Affidavit B-215 Step 8: Check the box next to "special mobile agricultural vehicle" if this is the type of vehicle being documented.

 

Connecticut Special Mobile Equipment Affidavit B-215 Step 9: Enter your signature in the first blank box at the bottom of the page.

 

Connecticut Special Mobile Equipment Affidavit B-215 Step 10: Enter the date in the second blank box.

 

Connecticut Special Mobile Equipment Affidavit B-215 Step 11: Submit the document to the Connecticut Department of Motor Vehicles.

 

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Form P-40 Initial Medical Request

Form P-40 Initial Medical Request

 

INSTRUCTIONS: CONNECTICUT INITIAL MEDICAL REQUEST (Form P-40)

 

 

When a Connecticut driver has been involved in an accident that may have been caused by an underlying medical condition, they may be required to receive an examination from a medical professional. This can be documented using a form P-40. This document can be obtained from the website of the government of Connecticut.

 

Connecticut Initial Medical Request P-40 Step 1: At the top right-hand corner, enter the driver's license number and the date of the incident in question.

 

Connecticut Initial Medical Request P-40 Step 2: The patient should enter their signature and the date in the first two blank boxes, then give the form to the examining medical professional for completion.

 

Connecticut Initial Medical Request P-40 Step 3: Enter the patient's last name, first name and middle initial in the third blank box.

 

Connecticut Initial Medical Request P-40 Step 4: Enter the patient's date of birth in the fourth blank box.

 

Connecticut Initial Medical Request P-40 Step 5: Enter the patient's telephone number in the fifth blank box.

 

Connecticut Initial Medical Request P-40 Step 6: Enter the patient's street address, city, state and zip code in the sixth blank box.

 

Connecticut Initial Medical Request P-40 Step 7: In the next section, place a check mark next to all listed conditions which may apply to the patient. The listed conditions are alcohol/substance abuse, Alzheimer's/dementia, cardiovascular/hypertension, cerebral palsy, cystic fibrosis, endocrine/glandular, liver/renal failure, narcolepsy, neurological/neuromuscular, ophthalmologic, orthopedic, peripheral vascular disease, psychiatric/emotional disorder, pulmonary/sleep apnea, or other. If the latter, provide a description.

 

Connecticut Initial Medical Request P-40 Step 8: In the next section, enter the conditions for which you have been treating the patient, the date on which treatment began and the date of the last examination.

 

Connecticut Initial Medical Request P-40 Step 9: If the patient has been treated by another physician, enter their name, office address and that physician's specialty.

 

Connecticut Initial Medical Request P-40 Step 10: If you believe the patient has no medical matters which would affect safe motor vehicle operation, indicate this with a check mark. If you do not have sufficient information to evaluate their ability to operate a motor vehicle safely, indicate this with a check mark. If you believe the patient should be road tested or evaluated for special equipment requirements, indicate this with a check mark.

 

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Form A-2 Self Sufficiency Income Chart in Forms Preparation and Data Validation

Form A-2 Self Sufficiency Income Chart in  Forms Preparation and Data Validation

 

INSTRUCTIONS: ALABAMA WIA SELF-SUFFICIENCY INCOME CHART (Appendix A (A-2))

 

 

This article discusses the Alabama Workforce Investment System (WIA) updated self-sufficiency income chart which was revised in 2008. Because the revised guidelines for this chart were implemented after the publication of the Forms Preparation Handbook for that year, it was necessary to update the information following this document's revision on April 25, 2008. The governor's letter requesting these changes and the chart can still be found on the website maintained by the Alabama Department of Economic and Community Affairs.

 

Alabama WIA Self-Sufficiency Income Chart Appendix A (A-2) Step 1: The first paragraph of the first page explains the purpose of this letter.

 

Alabama WIA Self-Sufficiency Income Chart Appendix A (A-2) Step 2: The second paragraph discusses the changes that must be made to the Self-Sufficiency Income Chart.

 

Alabama WIA Self-Sufficiency Income Chart Appendix A (A-2) Step 3: The third paragraph discusses the actions to be taken to implement these changes.

 

Alabama WIA Self-Sufficiency Income Chart Appendix A (A-2) Step 4: The fourth paragraph, which is located on the second page, contains contact information for obtaining further assistance in implementing these changes.

 

Alabama WIA Self-Sufficiency Income Chart Appendix A (A-2) Step 5: The third page contains the revised self-sufficiency income charts. Chart A contains the rates for metropolitan areas. All applicable counties falling into this category are listed. In the table provided, the size of the family is listed in the first column.

 

Alabama WIA Self-Sufficiency Income Chart Appendix A (A-2) Step 6: In the second column, the 100% Lower Living Standard Income Level (LLSIL) is listed.

 

Alabama WIA Self-Sufficiency Income Chart Appendix A (A-2) Step 7: In the third column, the 200^ Lower Living Standard Income Level rate is listed.

 

Alabama WIA Self-Sufficiency Income Chart Appendix A (A-2) Step 8: For families who have more than six members, the amount to be added for each additional family member is provided at the bottom of the table.

 

Alabama WIA Self-Sufficiency Income Chart Appendix A (A-2) Step 9: Table B provides rates for the other 39 Alabama counties not listed above which are classified as non-metropolitan areas. The family size for each rate is listed in the first column.

 

Alabama WIA Self-Sufficiency Income Chart Appendix A (A-2) Step 10: The 100% LLSIL for each family is given in the second column, while the 200% LLSIL is given in the third column.

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Form A-1-PE-9 Application for Professional Engineer Licensure

Form A-1-PE-9 Application for Professional Engineer Licensure

 

INSTRUCTIONS: ALABAMA APPLICATION FOR PROFESSIONAL ENGINEER LICENSURE (Form A-1-PE-9)

 

 

To apply for a professional engineer license in Alabama, file the form discussed in this article. This document can be obtained from the website maintained by the Alabama Board of Licensure for Professional Engineers and Land Surveyors.

 

Alabama Application For Professional Engineer Licensure A-1-PE-9 Step 1: On line 1, enter your full legal name.

 

Alabama Application For Professional Engineer Licensure A-1-PE-9 Step 2: On line 2, enter both your residential and firm address. Indicate which is preferred for mailing correspondence by placing an X in the appropriate box. Provide the telephone number for both addresses, as well as your email address.

 

Alabama Application For Professional Engineer Licensure A-1-PE-9 Step 3: On line 3, enter your date of birth.

 

Alabama Application For Professional Engineer Licensure A-1-PE-9 Step 4: On line 4, enter your Social Security number.

 

Alabama Application For Professional Engineer Licensure A-1-PE-9 Step 5: On line 5, indicate whether you are applying for licensure by comity or exam with a check mark. If comity, skip to line 6. If exam, indicate whether you failed the professional engineer in another state with a check mark. If so, give the state and the number of times, complete line 6, then skip to line 10.

 

Alabama Application For Professional Engineer Licensure A-1-PE-9 Step 6: On line 6, document as instructed Alabama or other states where you passed the Fundamentals of Engineering (FE) or professional engineer exams. 

 

Alabama Application For Professional Engineer Licensure A-1-PE-9 Step 7: On line 7, give the state and date of your first professional engineer licensure, as well as the date to which it is current.

 

Alabama Application For Professional Engineer Licensure A-1-PE-9 Step 8: On line 8. list other states in which you are licensed.

Alabama Application For Professional Engineer Licensure A-1-PE-9 Step 9: On line 9, indicate whether you hold a current NCEES record.

 

Alabama Application For Professional Engineer Licensure A-1-PE-9 Step 10: Answer lines 10 through 15 by checking "Yes" or "No" as applicable.

 

Alabama Application For Professional Engineer Licensure A-1-PE-9 Step 11: Document your undergraduate and graduate record in section 16, your experience in section 17, verification of your experience in section 18, and references in section 19. Complete sections 20 through 22 as instructed, then have section 23 certified by a notary public.

 

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Form IB14 State Employee Plan Change Form

Form IB14 State Employee Plan Change Form

 

INSTRUCTIONS: ALABAMA STATE EMPLOYEE PLAN CHANGE FORM (Form IB14)
 
Alabama state employees who wish to change their health insurance coverage do so by filing a form IB14. This form can be obtained from the website of the Alabama State Employees' Insurance Board.
 
Alabama State Employee Plan Change Form IB14 Step 1: At the top of the form, check the box next to the type of coverage you are seeking to obtain, or indicate if you are declining coverage.
 
Alabama State Employee Plan Change Form IB14 Step 2: On the first line enter your name, sex and the date on which coverage took effect.
 
Alabama State Employee Plan Change Form IB14 Step 3: On the second line enter your contact telephone number and date of birth.
 
Alabama State Employee Plan Change Form IB14 Step 4: On the third line enter your street address.
 
Alabama State Employee Plan Change Form IB14 Step 5: On the fourth line enter your city, state and zip code.
 
Alabama State Employee Plan Change Form IB14 Step 6: On the fifth line enter your home and work telephone numbers, as well as your email address.
 
Alabama State Employee Plan Change Form IB14 Step 7: The next four blank lines are provided to document dependents you are seeking coverage for. This is only required for those seeking basic coverage (SEHIP). On the first line, enter your spouse's name, birthdate and Social Security number.
 
Alabama State Employee Plan Change Form IB14 Step 8: On the next three lines, enter the same information for your children. Indicate their relationship to you by circling the appropriate label in the second column. 
 
Alabama State Employee Plan Change Form IB14 Step 9: If you are applying for supplemental coverage or Southland optional policies for vision, dental or cancer care or hospital indemnity, you must complete the last section documenting your primary insurance coverage. The first question asks you if this primary coverage has a spousal carve-out. Indicate "Yes" or "No" by circling the applicable response.
 
Alabama State Employee Plan Change Form IB14 Step 10: Provide all identifying information required about your health insurance company, as well as any dental coverage you have.
 
Alabama State Employee Plan Change Form IB14 Step 11: Sign and date the form. Mail it to the address given at the bottom of the second page.
 

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Form CL-472 Request for Reimbursement Preferred Health FSA/HRA

Form CL-472 Request for Reimbursement  Preferred Health FSA/HRA

 

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.

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License Cancellation/Termination Form

License Cancellation/Termination Form

 

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.

 

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