Marianas Air. November 07, US Department of Transportation Attn: Ms. Laura Remo 1200 New Jersey Avenue, SE Washington, DC
|
|
- Byron Little
- 5 years ago
- Views:
Transcription
1 ~,.. Marianas Air P.O. Box , San Jose Village, Tinian, MP November 07, 2012 US Department of Transportation Attn: Ms. Laura Remo 1200 New Jersey Avenue, SE Washington, DC Subject: Items Required By Docket DOT-OST Final Order Dear Ms. Remo; This letter is being sent to satisfy the requirements included in the Terms, Conditions, and Limitations attachment to the Final Order for Commuter Air Carrier certification for Star Marianas Air, Inc. Below the provisions set forth in paragraph (1) (a) through (d) of the Terms, Conditions, and Limitations attachment are reproduced and responded to with reference made to the Exhibit(s) included as enclosures to this letter. (1) The authority to conduct scheduled passenger operations will not become effective until six (business) days after the Department has received the following documents; provided, however, that the Department may stay the effectiveness of this authority at any time prior to that date: a) A copy of the holder's Air Carrier Certificate and Operations Specifications authorizing Commuter Operations from the Federal Aviation Administration (FAA). Response: A copy of Star Marianas Air, Inc.'s Air Carrier Certificate is attached to this document as Exhibit A, and a copy of Operations Specifications Part A001- Issuance and Applicability as Exhibit B. b) A certificate of insurance on OST Form 6410 evidencing liability insurance coverage meeting the requirements of 14 CFR 205.5(b) for all its aircraft. Response: A copy of OST Form 6410 is attached to this document as Exhibit C. c) A statement of any changes the holder undergone in its ownership, key personnel, operating plans, financial posture, or compliance history, since the date of the Show Cause Order in this case. Response: Since the date of the Show Cause order there has been a change to key management personnel with the designation with James E. Bell previously designated as Chief Pilot being designated as Director of Operations and the addition of James Mezzapeso a U.S. citizen and Pilot-In-Command being designated as Chief Pilot. Mr. Robert F. Christian remains on the Board of Directors. There have been no changes to Star Marianas Air, Inc.'s ownership, operating plans, financial posture, or compliance history since the date of the Show Cause Order. Tel.: /9989 Fax. : Web site:
2 r""" Marianas Air P.O. Box , San Jose Village, Tinian, MP Attached to this document as Exhibit Dis Star Marianas Air, Inc.' s Operation Specifications Part A006- Management Personnel. d) A revised list of pre-operating expenses already paid and those remaining to be paid, as well as independent verification that the holder has available to it funds sufficient to cover any remaining pre-operating expenses and to provide a working capital reserve equal to the operating costs that would be incurred in three months of operations. Response: The Company received independent verification as follows (See Exhibit E): All pre-operating expenses have been paid and no further pre-operating expenses will be incurred in the future. The company has currently a working capital reserve equal to the operating costs expected to be incurred in three months of operations. COMPLIANCE DISPOSITION The contents of this document and the attached exhibits(s) are true and correct to the best of my knowledge and belief Pursuant to Title 18 United States Code Section 1001, I Shoun Christian, in my individual capacity as the authorized representative of the applicant, have not in any manner knowingly and willfully falsified, concealed or failed to disclose any material fact or made any false, fictitious, or fraudulent statement or knowingly used any documents which contains such statements in connection with the preparation, filing or prosecution of the applicant. I understand that an individual who is found to have violated the provisions of 18 United States Code Section 1001 shall be fined or imprisoned not more than five years, or both. Please feel welcome to contact me should any additional information or clarification be needed. ~rely; ~ $( ~ Shaun R. Christian Executive Vice President Enclosures: Exhibit A- Air Carrier Certificate Exhibit B- Operations Specifications Part A001 Exhibit C-OST 6410 Exhibit D- Operations Specifications Part A006 Exhibit E- Response to Par. (1)(d) Tel.: /9989 Fax.: Web site:
3 Exhibit A Star Marianas Air, Inc. Air Carrier Certificate
4
5 Exhibit B Star Marianas Air, Inc. Operations Specifications Part A001 (Issuance and Applicability)
6
7
8 Exhibit C Star Marianas Air, Inc. OST 6410
9 AGENCY DISPLAY OF ESTIMATED BURDEN Office of the Secretary of Transportation The public reporting burden for this collection of information is estimated to average 30 minutes per response. If you wish to comment on the accuracy of the estimate or make suggestions for reducing this burden, please direct your comments to: U.S. Department of Transportation, Office of Aviation Analysis, X-56, th St., SW., Washington, D.C According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. NOTE: For information on where to file completed copies of this form, see FILING INSTRUCTIONS below. OMB No Expires U.S. AIR CARRIERS - CERTIFICATE OF INSURANCE POLICIES OF INSURANCE FOR AIRCRAFT ACCIDENT BODILY INJURY AND PROPERTY DAMAGE LIABILITY FILING INSTRUCTIONS: File a signed original of this form with the Federal Aviation Administration, AFS-260, 800 Independence Ave., S.W., Washington, D.C (See EXCEPTIONS 1 and 2 below.) EXCEPTION 1: If Block 2B on the reverse is filled in because the insured is a commuter air carrier, file a signed original of this form with the Department of Transportation, Air Carrier Fitness Division, X-56, th St., SW, Washington, DC EXCEPTION 2: For any insured that is located in the State of Alaska (regardless as to whether Block 2A, 2B, or 2C is filled in), file a signed original of this form with the Federal Aviation Administration, Alaskan Region Hq., AAL-230, 222 W. 7 th Ave., #14, Anchorage, Alaska (Please type information, except signatures.) THIS CERTIFIES THAT: XL Specialty Insurance Company has issued a policy or policies of Aircraft Liability Insurance to (Name of Insurer) FAA Star Marianas Air, Inc., 4335 Glendale-Milford Road, Cincinnati, OH Certificate Number ISMA230M (Name, address of Insured U.S. Air Carrier) effective from May 1, 2012 until ten (10) days after written notice from the insurer or carrier of the intent to terminate coverage is received by the Department of Transportation. NOTE: Part 205 of the Department s Regulations does not allow for a predetermined termination date, and a certificate showing such a date is unacceptable. 1. The Insurer (Check One): X is licensed to issue aircraft insurance policies in the United States; is licensed or approved by the government of to issue aircraft insurance policies; or is an approved surplus line insurer in the State(s) of 2. The insurer assumes, under the policy or policies listed below, aircraft accident liability insured to minimums at least equal to the following during operation, maintenance, or use of aircraft in air transportation as that term is defined in 49 U.S.C (Complete applicable section(s) A, B, or C below): A. U.S. AIR TAXI OPERATORS (EXCLUDING U.S. COMMUTER AIR CARRIERS) WITH PART 298 AUTHORITY ONLY: The aircraft covered by this policy are SMALL AIRCRAFT (i.e., with 60 or fewer passenger seats or with a maximum payload capacity of 18,000 pounds or less). (Complete separate or combined coverage as appropriate): Separate Coverages: Minimum Limit Policy Number Type of Liability Each Person Each Occurrence Bodily Injury Liability (Excluding Passengers) $75,000 $300,000 Passenger Bodily Injury $75,000 $75,000 x 75% of total number of passenger seats installed in aircraft Property Damage $100,000 X Combined Coverage: The amount of coverage set forth below is a single limit of liability for each occurrence at least equal to the required minimums stated above for bodily injury (excluding passengers), property damage, and passenger bodily injury. Policy Number UA AV12A Amount of Coverage $10,000,000 This policy covers CARGO operations only and excludes passenger liability insurance. OST Form 6410 B. U.S. COMMUTER AIR CARRIERS OR CERTIFICATED AIR CARRIERS OPERATING SMALL AIRCRAFT
10 The aircraft covered by this policy are SMALL AIRCRAFT (i.e., with 60 or fewer passenger seats or with a maximum payload capacity of 18,000 pounds or less). (Complete separate or combined coverage as appropriate): Separate Coverages: Minimum Limit Policy Number Type of Liability Each Person Each Occurrence Combined Bodily Injury (Excluding Passengers other than cargo attendants) and Property Damage Liability $300,000 $2,000,000 Passenger Bodily Injury $300,000 $300,000 x 75% of total number of passenger seats installed in aircraft Combined Coverage: The amount of coverage set forth below is a single limit of liability for each occurrence at least equal to the required minimums stated above for bodily injury (excluding passengers), property damage, and passenger bodily injury. Policy Number Amount of Coverage This policy covers CARGO operations only and excludes passenger liability insurance. C. U.S. CERTIFICATED AIR CARRIERS OPERATING LARGE AIRCRAFT The aircraft covered by this policy are LARGE AIRCRAFT (i.e., with more than 60 passenger seats or with a maximum payload capacity of more than 18,000 pounds). (Complete separate or combined coverage as appropriate): Separate Coverages: Minimum Limit Policy Number Type of Liability Each Person Each Occurrence Combined Bodily Injury (Excluding Passengers other than cargo attendants) and Property Damage Liability $300,000 $2,000,000 Passenger Bodily Injury $300,000 $300,000 x 75% of total number of passenger seats installed in aircraft Combined Coverage: The amount of coverage set forth below is a single limit of liability for each occurrence at least equal to the required minimums stated above for bodily injury (excluding passengers), property damage, and passenger bodily injury. Policy Number Amount of Coverage This policy covers CARGO operations only and excludes passenger liability insurance. 3. The policy or policies listed in this certificate insure(s) (Check One): Make and Model FAA or Foreign Flag Registration No. Operations conducted with all aircraft operated by the insured Piper PA Cherokee N4254R Operations conducted with the following types of aircraft: Piper PA Cherokee N4089W X Operations with the following aircraft: (Use additional page if necessary) Piper PA Cherokee N4127R Piper PA Cherokee Piper PA Cherokee Piper PA Cherokee Piper PA Cherokee 4. Each policy listed in this certificate meets or exceeds the requirements in 14 CFR Part 205. N4267R N4599X N8639N N166CB XL Specialty Insurance Company (Name of Insurer) One World Financial Center 200 Liberty Street, 3 rd Floor (Address) New York, NY (City, State, Zip Code) Richard DeMicco (Contact person who can verify the effectiveness of the coverage) / (Area Code, Phone Number) / (Area Code, Fax Number) (Name of Broker) (Address) (City, State, Zip Code) (Officer or authorized representative) (Area Code, Phone Number) / (Area Code, Fax Number) (Signature, if applicable) May 9, 2012 (Date) (Signature) (Date)
11 Exhibit D Star Marianas Air, Inc. Operations Specifications Part A006 (Management Personnel)
12
13 Exhibit E
14 Emerald Coast Consulting Services, Inc SW 117"' Ter Cooper City, Fl November 3, 2012 TO WHOM IT MAY CONCERN: I have compiled the financial statements for Star Marianas Air, Inc., for the years ended December 31, 2009, 2010, and 2011 and have been provided with current financial information for I have reviewed the Company's current financial position and results of operations and have reviewed with management the proposed scheduled passenger operations. On this basis, I can verify the following: All pre-operating expenses have been paid and no further pre-operating expenses will be incurred in the future. The company has currently a working capital reserve equal to the operating costs expected to be incurred in three months of operations. Respectfully submitted, -'77/77A--I/ es H. Weathersbee, CP ell: EST Aviation Financial Consulting
BEFORE THE DEPARTMENT OF TRANSPORTATION WASHINGTON, DC 20590
BEFORE THE DEPARTMENT OF TRANSPORTATION WASHINGTON, DC 20590 ) Application of Delux Public Charter, LLC ) For Authority to Conduct Passenger ) Operations as a Commuter Air Carrier ) DOT-OST-2015-0208 Pursuant
More informationBEFORE THE DEPARTMENT OF TRANSPORTATION WASHINGTON, D.C. ) ) ) ) ) ) ) )
BEFORE THE DEPARTMENT OF TRANSPORTATION WASHINGTON, D.C. Application of EJME (PORTUGAL AIRCRAFT MANAGEMENT, LDA for an exemption pursuant to 49 U.S.C. 40109 and a foreign air carrier permit pursuant to
More informationUSAIG Certificate of Insurance
USAIG Certificate of Insurance This is to certify to: To Whom It May Concern and/or any Member State of the European Union (EU) that: whose address is: ExecuJet Charter Service, Inc. and Executive Aircraft
More informationDate. Employee Name: File Number: Telephone Number: JOHN Q. CLAIMANT 1111 MAIN STREET OAK RIDGE, TN Dear Mr. Claimant:
Date Employee Name: File Number: Telephone Number: JOHN Q. CLAIMANT 1111 MAIN STREET OAK RIDGE, TN 44444 Dear Mr. Claimant: The information requested in the attached enclosure is required in connection
More informationGENERAL AVIATION AIRPORT LIABILITY APPLICATION
GENERAL AVIATION AIRPORT LIABILITY APPLICATION This Application does not commit the Insurer to any liability nor make the Applicant liable for any premium unless and until Phoenix Aviation Managers, Inc.,
More informationApplication For Non-Owned Aircraft Liability Insurance
Application For Non-Owned Aircraft Liability Insurance APPLICATION (2017) NAME OF APPLICANT (including D/B/A s And Holding Companies): ADDRESS: c\o Garden State Municipal Joint Insurance Fund BUSINESS
More informationLIBERTY INSURANCE UNDERWRITERS INC. (A Stock Insurance Company, hereinafter the Company ) 55 Water Street, 23rd Floor, New York, NY 10041
Toll-free number: 1-66-434-557 LIBERTY INSURANCE UNDERWRITERS INC. (A Stock Insurance Company, hereinafter the Company ) 55 Water Street, 23rd Floor, New York, NY 10041 RENEWAL APPLICATION UNLESS OTHERWISE
More informationBEFORE THE DEPARTMENT OF TRANSPORTATION OFFICE OF AVIATION ENFORCEMENT AND PROCEEDINGS WASHINGTON, D.C.
BEFORE THE DEPARTMENT OF TRANSPORTATION OFFICE OF AVIATION ENFORCEMENT AND PROCEEDINGS WASHINGTON, D.C. ------------------------------------------------------, third-party complainant v. Docket DOT-OST-2014-
More informationNon-Owned Aircraft Insurance Application
Non-Owned Aircraft Insurance Application Name of Applicant: Street Address: City: State: Zip Code: Telephone Number: Corporate Website: Email Address: Quotation for the following insurance is requested
More informationLocal Switching Support Instructions for Support Calculation
Approved by OMB 3060-0814 Ave. Burden Estimate per Respondent: 24 Hours NOTICE: The collection of information stems from the Commission s authority under Section 254 of the Communications Act of 1934,
More informationSUMMARY: The Department of the Treasury s Office of Foreign Assets Control (OFAC) is
This document is scheduled to be published in the Federal Register on 04/15/2016 and available online at http://federalregister.gov/a/2016-08720, and on FDsys.gov DEPARTMENT OF THE TREASURY Office of Foreign
More informationFederal Deposit Insurance Corporation Washington, D.C
FORM 3 Federal Deposit Insurance Corporation Washington, D.C. 20429 Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 (PLEASE PRINT OR TYPE ALL RESPONSES) OMB APPROVAL OMB NUMBER:
More informationRPG DIRECTORS & OFFICERS LIABILITY
RPG DIRECTORS & OFFICERS LIABILITY including Employment Practices Liability for Not-for-Profit Organizations (Claims-made Coverage) Insurance Program and Enrollment Form This brochure is valid for effective
More informationDisclosure Statement and Authorization
Disclosure Statement In connection with your employment or application for employment with (the Company), the Company may obtain or prepare consumer reports or investigative consumer reports on you to
More informationFor faster claim payment* please submit your claim online at
Claims Made Easy For faster claim payment* please submit your claim online at www.combinedinsurance.com/claims FILING A CLAIM BY MAIL 1. Download the claim form 2. Print all six pages of the claim form
More informationW. BROWN & ASSOCIATES INSURANCE SERVICES
W. BROWN & ASSOCIATES INSURANCE SERVICES AIRCRAFT HULL & LIABILITY INSURANCE APPLICATION Check which is desired: Quotation Insurance RETURN TO: W. BROWN & ASSOCIATES INSURANCE SERVICES Aviation Managers
More informationGREAT AMERICAN ASSURANCE COMPANY Real Estate Professional Errors & Omissions Insurance. EXPRESS Application. if you are not eligible for this program.
GREAT AMERICAN ASSURANCE COMPANY Real Estate Professional Errors & Omissions Insurance EXPRESS Application To be eligible for this application you must be able to answer "True" to statements 1-7 below.
More informationMedicare. If you have any other questions, please feel free to call us at MEDICARE ( ). Sincerely,
Medicare Beneficiary Services:1-800-MEDICARE (1-800-633-4227) TTY/ TDD:1-877-486-2048 Thank you for your recent request for the Patient s Request for Medical Payment form (CMS-1490S). Enclosed is the form,
More informationRPG DIRECTORS & OFFICERS LIABILITY
RPG DIRECTORS & OFFICERS LIABILITY including Employment Practices Liability for Not-for-Profit Organizations (Claims-made Coverage) Insurance Program and Enrollment Form This brochure is valid for effective
More informationAPPLICATION CHECKLIST Motor Common Carrier or Motor Contract Carrier Of Household Goods in Use
APPLICATION CHECKLIST Motor Common Carrier or Motor Contract Carrier Of Household Goods in Use Use this checklist to make sure you have enclosed all required items or your application will not be processed.
More informationStandard Program Employment Practices Liability Insurance Houston Casualty Company
Standard Program Employment Practices Liability Insurance Houston Casualty Company Section 1. General Information Name of Applicant Organization: Please type or print clearly Renewal Application Mailing
More informationCapitol Specialty Insurance Corporation A Stock Company. Miscellaneous Medical General Application
Capitol Specialty Insurance Corporation A Stock Company P. O. Box 5900 Madison, WI 53705 0900 Miscellaneous Medical General Application NOTE: NOTHING IN THIS APPLICATION SHOULD BE INTERPRETED TO MEAN THAT
More informationZURICH AMERICAN INSURANCE COMPANY BLANKET ACCIDENT INSURANCE POLICY PROOF OF COVERED LOSS FORM Mail claims to: INSTRUCTIONS
ZURICH AMERICAN INSURANCE COMPANY BLANKET ACCIDENT INSURANCE POLICY PROOF OF COVERED LOSS FORM Mail claims to: Administrative Concepts, Inc. 994 Old Eagle School Road Suite 1005 Wayne, PA 19087-1802 www.visit-aci.com
More informationApplication to the U. S. Department of Labor for Expedited Review of Denial of COBRA Premium Reduction
Print Form Application to the U. S. Department of Labor for Expedited Review of Denial of COBRA Premium Reduction GENERAL INFORMATION: If you or a family member has lost employment, a new law may make
More informationULI205 Page 1 of 6. Date: Signature: Print Name:
Administrator s Office PO BOX 25326 Overland Park, Kansas 66225-5326 1-800-237-4463 Unified Life Insurance Company ACCIDENT/SICKNESS DISABILITY CLAIM FORM INSURED S PORTION Insured Name: Address: Date
More informationUSG Insurance Services, Inc. Application for Helicopter Hull and Liability Insurance
USG Insurance Services, Inc. Application for Helicopter Hull and Liability Insurance CHECK WHICH IS DESIRED: A QUOTATION INSURANCE POLICY RENEWAL POLICY Name of Applicant (Including D/B/A s and Holding
More informationAIRCRAFT INSURANCE APPLICATION
1. Name of Applicant: AIRCRAFT INSURANCE APPLICATION 2. Mailing Address: 3. Effective Dates: From: To: Both at 12:01 AM standard time at the address above 4. Business of Applicant:: 5. Former Business
More informationAGREEMENT BY ERICKSON, KAWERAK, AND DOT FOR ATNEP COMPENSATION FOR AIR TRANSPORATION AT DIOMEDE, ALASKA,
AGREEMENT BY ERCKSON, KAWERAK, AND DOT FOR ATNEP COMPENSATON FOR AR TRANSPORATON AT DOMEDE, ALASKA, -,...1:,.':. BACKGROUND AND PURPOSE,; J, ~..-. ~..., r:.,_} :f This agreement is entered into by and
More informationPLEASE KEEP THIS FOR YOUR RECORDS AND FOR FUTURE REFERENCE.
U.S. DEPARTMENT OF LABOR n PLEASE KEEP THIS FOR YOUR RECORDS AND FOR FUTURE REFERENCE. Instructions Complete, sign, date, and return the enclosed REPORT OF CHANGES form, in the envelope provided, to your
More informationMedicare. If you have any other questions, please feel free to call us at MEDICARE ( ). Sincerely,
Medicare Beneficiary Services:1-800-MEDICARE (1-800-633-4227) TTY/ TDD:1-877-486-2048 Thank you for your recent request for the Patient s Request for Medical Payment form (CMS- 1490S). Enclosed is the
More informationDavid A. Collier Area Manager Regulatory
David A. Collier Area Manager Regulatory AT&T Services, Inc. 645 East Plumb Lane, C142 P.O. Box 11010 Reno, NV 89520 Via E-Filing and Overnight Mail 775-333-3986 Phone 775-333-2364 Fax david.collier@att.com
More informationTRAVEL Policy Application (not available in NJ, NY and PR)
TRAVEL Policy Application (not available in NJ, NY and PR) Print or type only This Policy Application, upon acceptance and approval by Nationwide Life Insurance Company Columbus, Ohio will become a part
More informationREPORT OF FOREIGN BANK AND FINANCIAL ACCOUNTS. Do NOT file with your Federal Tax Return
TD F 90-.1 (Rev, October 08) Department the Treasury REPORT OF FOREIGN BANK AND FINANCIAL ACCOUNTS 1 OMB No. 45- This Report is for Calendar Year Ended 12/ Do not use previous editions this form after
More informationW. BROWN & ASSOCIATES INSURANCE SERVICES
W. BROWN & ASSOCIATES INSURANCE SERVICES AVIATION GENERAL LIABILITY INSURANCE APPLICATION Check which is desired: Quotation Insurance RETURN TO: W. BROWN & ASSOCIATES INSURANCE SERVICES Aviation Managers
More informationACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE
ACCOUNTANTS PROFESSIONAL LIABILITY INSURANCE GREAT AMERICAN ASSURANCE COMPANY EXPRESS APPLICATION To be eligible for this application you must be able to answer "True" to statements 1-9 below. Please contact
More informationEVENT PARTY OR WEDDING PLANNER SUPPLEMENTAL APPLICATION
EVENT PARTY OR WEDDING PLANNER SUPPLEMENTAL APPLICATION Applicant s Name TO BE USED WITH COMMERCIAL GENERAL LIABILITY APPLICATION (ACORD 125) All questions must be answered in full. Application must be
More informationLifeline Program Application Form
Enclosed please find the you recently requested. Please remember to do the following: 1. Complete and return ALL pages of 2. Select all applicable government programs or income eligibility criteria in
More informationNATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY CLAIM FORM INSTRUCTIONS
NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY CLAIM FORM INSTRUCTIONS THIS CLAIM CANNOT BE PROCESSED WITHOUT ALL OF THE BELOW INFORMATION AND STATEMENTS OF PAYMENTS FROM THE OTHER PLANS.
More informationSMALL ACCOUNTING FIRM PROFESSIONAL LIABILITY APPLICATION NAVIGATORS INSURANCE COMPANY
SMALL ACCOUNTING FIRM PROFESSIONAL LIABILITY APPLICATION NAVIGATORS INSURANCE COMPANY NOTICE: This is an application for a Claims-made policy. Coverage for prior acts and claims made after termination
More informationFederal Reserve Bank of Dallas
Federal Reserve Bank of Dallas 2200 N. PEARL ST. DALLAS, TX 75201-2272 June 11, 2003 Notice 03-31 TO: The Chief Executive Officer of each financial institution and others concerned in the Eleventh Federal
More informationLIFELINE SUPPLEMENTAL INFORMATION
LIFELINE SUPPLEMENTAL INFORMATION Select the service to which to apply your Lifeline benefit: Phone Broadband To apply for a federal Lifeline benefit, make sure to: 1. Fill out every section of this form.
More informationCHUBB WORKPLACE BENEFITS A BUSINESS UNIT OF COMBINED INSURANCE COMPANY OF AMERICA, A CHUBB COMPANY INSTRUCTIONS FOR FILING CLAIMS
CHUBB WORKPLACE BENEFITS A BUSINESS UNIT OF COMBINED INSURANCE COMPANY OF AMERICA, A CHUBB COMPANY INSTRUCTIONS FOR FILING CLAIMS GETTING STARTED Follow the Claimant Instructions below to complete the
More informationAIRPORT LIABILITY APPLICATION
AIRPORT LIABILITY APPLICATION Applicant s Name: Mailing Address: Effective from until both at 12:01 a.m. standard time at the address above. Applicant is: Government Corporation Partnership (Name all partners):
More informationNATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY CLAIM FORM CLAIM FILING INSTRUCTIONS NOTE TO ORGANIZATIONS AND PATIENT
NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY CLAIM FORM THIS CLAIM CANNOT BE PROCESSED WITHOUT ALL OF THE BELOW INFORMATION AND STATEMENTS OF PAYMENTS FROM THE OTHER PLANS. CLAIM FILING
More informationST JOE CO Filed by THIRD AVENUE MANAGEMENT LLC
ST JOE CO Filed by THIRD AVENUE MANAGEMENT LLC FORM SC 13G (Statement of Ownership) Filed 07/10/08 Address 245 RIVERSIDE AVENUE STE 500 JACKSONVILLE, FL 32202 Telephone 9043014200 CIK 0000745308 Symbol
More informationLIFELINE SUPPLEMENTAL INFORMATION
LIFELINE SUPPLEMENTAL INFORMATION Select the service to which to apply your Lifeline benefit: Phone Broadband To apply for a federal Lifeline benefit, make sure to: 1. Fill out every section of this form.
More informationCLAIM FORM. DATE OF BIRTH: 3. PATIENT'S NAME & ADDRESS- IF ADDRESS IS NEW, PLEASE CHECK BOX r PHONE: ( )
PRIMERICA LIFE INSURANCE COMPANY as Administered by Senior Health Ins. Co. of Pennsylvania Home Office: Boston, MA P.O. Box 64913 St. Paul, MN 55164 Telephone: 1-877-451-5824 CLAIM FORM The patient or
More informationBANKERS TRUST COMPANY One Bankers Trust Plaza New York, New York Vice President P.O. Box 318. New York, NY
BANKERS TRUST COMPANY One Bankers Trust Plaza New York, New York 10006 Don R. De Souza Mailing Address: Vice President P.O. Box 318 Telephone: 212-250-2216 Church Street Station New York, NY 10008 February
More informationReal Estate Claims-Made Professional Liability Insurance Application
Real Estate Claims-Made Professional Liability Insurance Application Herbert H. Landy Insurance Agency Inc. 75 Second Avenue, Suite 410 Needham MA 02494 Phone: (800) 336-5422 Fax: (800) 344-5422 Visit
More informationIndividual Application Oklahoma
GREAT AMERICAN ASSURANCE COMPANY Real Estate Appraisers Errors & Omissions Insurance Individual Application Oklahoma This application is for an individual who only does 100% Real Estate Appraisal work.
More informationDate: January 9, 2015 All Approved Mortgagees Mortgagee Letter
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT WASHINGTON, DC 20410-8000 ASSISTANT SECRETARY FOR HOUSING- FEDERAL HOUSING COMMISSIONER Date: January 9, 2015 To: All Approved Mortgagees Mortgagee Letter
More informationMEDICARE DMEPOS COMPETITIVE BIDDING PROGRAM
DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-1016 For CMS Use Only MEDICARE DMEPOS COMPETITIVE BIDDING PROGRAM. Competitive Bidding Area (CBA)
More informationSPECIAL EVENT APPLICATION
1. Named Insured (applicant): 2. Mailing Address: 3. City: State: Zip: Phone: 4. Name of Event: Location of Event: (name of facility, city, state) 5. Description of Event, including schedule (attach brochure
More informationAIRCRAFT HULL & LIABILITY INSURANCE APPLICATION
Post Office Box 440757 Kennesaw, Georgia 30160 Applicant Name: Street: Business of Applicant: Effective from to AIRCRAFT HULL & LIABILITY INSURANCE APPLICATION Policy. (if known) If Airworthiness Certificate
More informationInstruction to be followed in Preparing and Filing the Application for Motor Common or Contract Carrier of Persons
PUC 178 (revised 4/09): Motor Common or Contract Carrier of Persons. Instruction to be followed in Preparing and Filing the Application for Motor Common or Contract Carrier of Persons You must be at least
More informationDEPARTMENT OF TRANSPORTATION. National Highway Traffic Safety Administration. [Docket No. NHTSA ]
This document is scheduled to be published in the Federal Register on 05/16/2018 and available online at https://federalregister.gov/d/2018-10427, and on FDsys.gov DEPARTMENT OF TRANSPORTATION National
More informationOMB APPROVAL EDITION What is a household? Be honest on this form. You may need to show other documents
1. About Lifeline Lifeline is a federal benefit that lowers the monthly cost of phone or internet service. Rules If you qualify, your household can get Lifeline for phone or internet service, but not both.
More informationPROFESSIONAL LIABILITY INSURANCE FOR AGENTS AND BROKERS APPLICATION
COMPANY PROVIDING COVERAGE: Greenwich Insurance Company Indian Harbor Insurance Company PROFESSIONAL LIABILITY INSURANCE FOR AGENTS AND BROKERS APPLICATION NOTICE The Insurance coverage for which you are
More informationInstructions for Completing this Application GENERAL INFORMATION. 1. Name of Applicant: 2. Business Address:
This completed document should be submitted to: ALTRU, LLC 3975 Erie Avenue Cincinnati, OH 45208 T: 800-529-8850 www.altru.com OLD REPUBLIC INSURANCE COMPANY MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION
More informationNATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY VOLUNTEER GROUP INSURANCE
Claim Form NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY VOLUNTEER GROUP INSURANCE Group Insurance NOTE: PLEASE READ THIS BEFORE SUBMITTING CLAIM PLEASE FILL OUT ALL SECTIONS -INSTRUCTIONS-
More informationIf you have any other questions, please feel free to call us at MEDICARE ( ). Sincerely,
Thank you for your recent request for the Patient s Request for Medical Payment form (CMS 1490S). Enclosed is the form, instructions for completing it, and where to return the form for processing. Please
More informationDraft Not for Reproduction 05/18/2016
Instructions for Request for Reduced Fee Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-942 OMB No. 1615-0116 Expires 05/31/2015 What Is the Purpose of Form I-942?
More informationATTENTION! READ THIS FIRST!!
ATTENTION! READ THIS FIRST!! How to File an Allstate Cancer Claim: Please call our office with any questions 877-282-0808 1. Please follow the instruction on the first page of the claim form. To continue
More informationLifeline Application Addendum Montana
Lifeline Application Addendum Montana If you are applying for Lifeline under the Medicaid program you qualify for an additional state Lifeline credit and must fill out the form below. Please be sure to
More informationUnmanned Aircraft Hull & Liability Insurance Application
Unmanned Aircraft Hull & Liability Insurance Application APPLICANT CONTACT INFORMATION Name: email: Phone: APPLICANT INFORMATION Business Name: FIRST LAST Address: Applicant's website: Business of Applicant:
More informationSupplemental Nutrition Assistance Program (SNAP) Preliminary Authorization of Food Purchasing and Delivery Services for the Elderly or Disabled
Food and Nutrition Service (FNS) Supplemental Nutrition Assistance Program (SNAP) Preliminary Authorization of Food Purchasing and Delivery Services for the Elderly or Disabled Request for Volunteers (RFV)
More informationWhat is a household? Be honest on this form
1. About Lifeline Lifeline is a federal benefit that lowers the monthly cost of phone or internet service. Rules If you qualify, your household can get Lifeline for phone or internet service, but not both.
More informationUSAC Service Provider Identification Number (1) Serving Area (2) b) Data Month
FCC Form 497 LIFELINE AND LINK UP WORKSHEET Approved by OMB July 2008 Edition 3060-0819 USAC Service Provider Identification Number (1) Serving Area (2) (3) (4) Company Name: Mailing Address: a) Submission
More informationUAV/UAS (DRONE) INSURANCE POLICY APPLICATION
https://aerialvehicleinsurance.com Underwriting@AerialVehicleInsurance.com 5 W Hargett St, 4th Floor, Raleigh NC 27601 T: 800 373 2804 F: 919 834 7039 404 Av De La Constitución, #708, San Juan PR 00901
More informationMay 3, Re: Disclosure of Liabilities and Assets on President Donald J. Trump s Public Financial Disclosure Report
May 3, 2018 The Honorable Rod J. Rosenstein Deputy Attorney General U.S. Department of Justice 950 Pennsylvania Ave., N.W. Washington, D.C. 20530-0001 Robert Khuzami Deputy United States Attorney United
More informationPharma-Bio Serv, Inc.
SECURITIES & EXCHANGE COMMISSION EDGAR FILING Pharma-Bio Serv, Inc. Form: SC 13D Date Filed: 2014-03-27 Corporate Issuer CIK: 1304161 Symbol: PBSV SIC Code: 8742 Fiscal Year End: 10/31 Copyright 2014,
More informationSECURITIES AND EXCHANGE COMMISSION Washington, D.C SCHEDULE 13G. Under the Securities Exchange Act of 1934 (Amendment No.
FORM SC 13G SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 SCHEDULE 13G Under the Securities Exchange Act of 1934 (Amendment No. )* Riot Blockchain, Inc. (Name of Issuer) Common Stock, no par
More informationCLAIM FOR DAMAGE, INSTRUCTIONS: Please read carefully the instructions on the FORM APPROVED INJURY, OR DEATH
CLAIM FOR DAMAGE, INSTRUCTIONS: Please read carefully the instructions on the FORM APPROVED INJURY, OR DEATH reverse side and supply information requested on both sides of this OMS NO. 1105-0008 form.
More informationCITA Insurance Services Insurance Agents, Brokers, and Consultants Errors & Omissions Insurance Application for Claims Made and Reported Coverage
Source: [sourcereferral] CITA Insurance Services Insurance Agents, Brokers, and Consultants Errors & Omissions Insurance Application for Claims Made and Reported Coverage 1. Applicant Information: Applicant
More informationUNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C SCHEDULE 13G. Algodon Wines & Luxury Development Group, Inc.
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 SCHEDULE 13G Under the Securities Exchange Act of 1934 (Amendment No. 1)* Algodon Wines & Luxury Development Group, Inc. (Name of
More informationTrip Delay. 3. Please upload the completed and signed claim form and all required documents to myclaimsagent.com or mail to:
Trip Delay HOW TO FILE A CLAIM 1. Complete all items on the attached claim form. 2. Attach the following documents (as applicable): Confirmation of the non-refundable amounts for the unused Common Carrier
More informationFinancial Institution Bond Application
FDIC #: DATE: *To be able to save this form after the fields are filled in, you will need to have Adobe Reader 9 or later. If you do not have version 9 or later, please download the free tool at: http://get.adobe.com/reader/.
More informationBusiness License Application (January 1 December 31)
4035 WALNUT CIRCLE / P.O. BOX 99 OAKWOOD GA 30566 770-534-2365 Business License Application (January 1 December 31) Date: Please check one: [ ] Mail (if mailed, please add and $1.25 for postage) [ ] Pick-up
More informationOCCUPATIONAL TAX CERTIFICATE
CITY OF JONESBORO 124 North Avenue Jonesboro, Georgia 30236 City Hall: (770) 478-3800 Fax: (770) 478-3775 www.jonesboroga.com OCCUPATIONAL TAX CERTIFICATE APPLICATION ATTACH ADDITIONAL PAGES IF NECCESSARY.
More informationED FORM 2000 OMB No Expiration Date: 04/30/2007. U. S. Department Of Education Federal Family Education Loan Program
ED FORM 2000 OMB No. 1845-0026 Expiration Date: 04/30/2007 U. S. Department Of Education Federal Family Education Loan Program Guaranty Agency Financial Report Cover Page Guaranty Agency State Name: Guaranty
More informationOWENS CORNING Filed by OWENS CORNING/FIBREBOARD ASBESTOS PERSONAL INJURY TRUST
OWENS CORNING Filed by OWENS CORNING/FIBREBOARD ASBESTOS PERSONAL INJURY TRUST FORM SC 13D/A (Amended Statement of Beneficial Ownership) Filed 04/09/14 Address ONE OWENS CORNING PARKWAY TOLEDO, OH, 43659
More informationBACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM
BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM In the interest of maintaining the safety and security of our customers, employees and property, Central Christian Church and its ministries (hereafter
More informationSPECIAL EVENTS LIABILTY APPLICATION
Section 1: CONTACT INFORMATION How did you hear about us? Contact Name: Corporate Name: Section 2: EVENT INFORMATION SPECIAL EVENTS LIABILTY APPLICATION DIRECTIONS: 1. Fill in the application by filling
More informationInstructions for Contract Between Sponsor and Household Member
Instructions for Contract Between Sponsor and Household Member Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-864A OMB No. 1615-0075 Expires 03/31/2020 What Is the
More informationThank you. Should you have any questions, please call us at (800)
Dear Policyholder: Please complete and sign the attached claim form. Additionally, the following items are needed in order to process your Medical/Dental claim in the most efficient and expedient way possible.
More informationSmall Disadvantaged Business Certification Application Community Development Corporation (CDC) Owned Concern
OMB Approval No. 3245-0317 To be completed by Private Certifier or SBA Name of Private Certifier Private Certifier ID Number Date Application Received: SDB Case #: Small Disadvantaged Business Certification
More informationAdministrator v. Raphael Pirker NTSB Docket No. CP-217
U.S. Department of Transportation Federal Aviation Administration July 18, 2013 Eastern Region Telephone: 718 553-3269 Facsimile: 718 995-5699 1 Aviation Plaza Jamaica, NY 11434 CERTIFIED MAIL RETURN RECEIPT
More informationINSTRUCTIONS FOR FILING GROUP VOLUNTARY STD / LTD / WAIVER OF PREMIUM CLAIMS
CLAIM FORM AND INSTRUCTIONS If you have any questions regarding our determination of your claim, or if you would like to appeal any determination, please contact our Customer Care Center at 1-800-348-4489
More informationPURCHASER ELIGIBILITY CERTIFICATION. Sale/Loan Pool Number(s):
OMB Number: 3064-0135 Expiration Date: 05/31/2012 PURCHASER ELIGIBILITY CERTIFICATION Sal: The purpose of the Purchaser Eligibility Certification is to identify Prospective Purchasers who are not eligible
More informationIf you should have any questions about the process for obtaining your 2016 Occupational License please contact the City Hall:
Dear Home Occupation Owner: Attached is the application for a Home Occupation Tax Certificate. All Home Occupation Tax Certificates must be approved by City Council. Please note that the application must
More informationCommercial General Liability Application
Commercial General Liability Application All questions must be answered in full. Application must be signed and dated by the applicant. Applicant s Name Agent Applicant Mailing Address Applicant s Phone
More informationUNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C SCHEDULE 13D. Under the Securities Exchange Act of 1934 (Amendment No.
SEC 1746 (11-2) Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. UNITED
More informationNew York Life Insurance Company
The Company You Keep New York Life Insurance Company Group Membership Association Claims PO Box 30782 Tampa FL 33630-3782 (800) 792-9686 Dear Beneficiary: Please accept our condolences on your recent loss.
More informationAPPLICATION CHECKLIST Motor Common Carrier of Persons in Group and Party Service Vehicles Seating 11 to 15 Passengers, including the Driver
APPLICATION CHECKLIST Motor Common Carrier of Persons in Group and Party Service Vehicles Seating 11 to 15 Passengers, including the Driver Use this checklist to make sure you have enclosed all required
More informationOMB APPROVAL EDITION What is a household? Be honest on this form. You may need to show other documents
1. About Lifeline Lifeline is a federal benefit that lowers the monthly cost of phone or internet service. Rules If you qualify, your household can get Lifeline for phone or internet service, but not both.
More informationAPPLICATION CHECKLIST Motor Contract Carrier of Persons
APPLICATION CHECKLIST Motor Contract Carrier of Persons Use this checklist to make sure you have enclosed all required items or your application will not be processed. You cannot operate in Pennsylvania
More informationParent Company Only Financial Statements for Large Holding Companies FR Y-9LP
OMB Number 7100-0128 Approval expires July 31, 2018 Page 1 of 9 Last Update: 20151112.075905 Board of Governors of the Federal Reserve System Parent Company Only Financial Statements for Large Holding
More informationPERSONAL INQUIRY WAIVER AUTHORITY FOR RELEASE OF INFORMATION FORM (Consumer Disclosure and/or Investigation for Background Check)
PERSONAL INQUIRY WAIVER AUTHORITY FOR RELEASE OF INFORMATION FORM (Consumer Disclosure and/or Investigation for Background Check) Disclosure Regarding Background Investigation In accordance with the U.S.
More informationILLINOIS UNIFIED CERTIFICATION PROGRAM DBE NO CHANGE AFFIDAVIT
ILLINOIS UNIFIED CERTIFICATION PROGRAM DBE NO CHANGE AFFIDAVIT Name of Firm: Address: City/State/Zip Code: Telephone No.: ( ) - Fax No.: ( ) - E-mail: Federal Employer ID No.: Contact Person: Title: List
More informationAdverse Action Guide for Employers: A Simplified Guide to the Fair Credit Reporting Act
This information presented here is not legal advice and is presented for general education purposes ONLY. BackTrack recommends that you consult with legal counsel for advice and opinions. Adverse Action
More information