Services.amerisafe.com

BENEFIT PLAN Extraterritorial

Web1 Aetna Life Insurance Company Hartford, Connecticut 06156 Extraterritorial Certificate Rider(GR-9N-CR1) Policyholder: Amerisafe, Inc. Group Policy No.: GP-881667

Actived: 1 days ago

URL: https://services.amerisafe.com/benefits/SummaryPlanDocuments/All%20Other%20States%20Not%20Listed%20-%20Generic/Extra%20Territorial%20State%20Riders.pdf

EMPLOYEE BENEFIT PLAN FOR EMPLOYEES OF AMERISAFE, INC.

WebUnder the 2010 Health Care Reform legislation, individuals enrolled in a group health plan or health insurance coverage have the right to (1) choose a primary care

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CRITICAL ILLNESS WELLNESS BENEFIT CLAIM FORM …

WebCAF001CIWSB CRITICAL ILLNESS WELLNESS BENEFIT CLAIM FORM INSTRUCTIONS Please use black or blue ink only and print legibly when completing this form in its entirety.

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Allstate at Work group voluntary cancer insurance

WebBenefit is limited to one visit by one physician each day of hospital confinement.Admission to the hospital as an inpatient is required. LOW OPTION HIGH OPTION. Allstate …

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APPLICATION FOR FAMILY AND MEDICAL LEAVE

WebUnder the Family and Medical Leave Act, if you have worked for this Company at least one year and at least 1,250 hours in the past 12 months, you are eligible for up to 12 weeks …

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Hospital GAP PLAN

WebSB-30116(LA)(CLASSIC)-0516 G-923 Series This policy is endorsed/sponsored by an association or issued through a trust in which the employer is a member, is intended to …

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Environmental, Health & Safety Training

WebWith access to over 600 training programs, streaming video is a convenient way to access training content on-demand, without having to maintain a physical DVD library.

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Your Davis Vision Designer Plan Benefits

WebWelcome to Davis Vision! We are pleased to provide you with information on your vision benefit to help you care for your vision and eye health - a key part of overall health and …

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AMERISAFE Dental Summaries

Web10/17/2013 09:49:48 2873183/15/16 Dental PPO Good news about dental benefits for employees of AMERISAFE, Inc. Why is dental health so important?

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REQUEST FOR MEDICAL REIMBURSEMENT

Web1. Fully complete the claim form. 2. For claim consideration of physician office or clinic visit, please submit the itemized bills including diagnosis to the address or fax number above. …

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Membership Cards

WebAssurant Focus Dental Network SM (Includes Aetna Dental® Administrators) To locate a network dentist – visit www.assurantemployeebenefits.com and select “Find a dentist”. …

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Certification of Health Care Provider for Family Member’s …

WebSECTION III: For Completion by the HEALTH CARE PROVIDER INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under the …

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Direct Reimbursement Claim Form Important Information: …

WebDirect Reimbursement Claim Form Important Information: 1. Use this form to request reimbursement for services received from providers who do not participate in the Davis …

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2012 EMPLOYEE BENEFITS HANDBOOK

WebAll Annual Salaries of $108 ,333 and above have a monthly cost of $66.25. NOTE: Please refer to your Lincoln Financial Certificate of Coverage for details. If this summary of …

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ACCIDENT CLAIM FORM INSTRUCTIONS

WebPost Office Box 84075 * Columbus, GA. 31993 . Phone (800) 433-3036 * Fax (866) 849-2970 . [email protected] . ACCIDENT CLAIM FORM INSTRUCTIONS

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Certification of Health Care Provider for Employee’s Serious …

WebPage 1 Form WH-380-E Revised May 2015 Certification of Health Care Provider for U.S. Department of Labor Employee’s Serious Health Condition Wage and Hour Division …

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Policy Highlights

WebEmployee $20,000 is the ONLY Option Offered Spouse at $10,000 Children at 50% ($10,000) each at no cost

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2016 Wellness Exam Certification Form

WebSECTION I: TO BE COMPLETED BY EMPLOYEE (PLEASE PRINT) Name: _____ Address: _____ City: _____ State: _____ Zip: _____

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Aetna Life Insurance Company

WebGR-96447 4 Project Rider - 904 Charges incurred for the following are not included: • a diabetic education program whose only purpose is weight control; or which is available to …

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