Print pa insurance license online
[DOCX File]FEDERAL TAX ID (EIN) NUMBER
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Return the following, by the date specified, to the address on the License Renewal Notice: this renewal addendum, renewal fee, and any necessary attachments. or. RENEW ONLINE AT . WWW.SIRCON.COM. We no longer mail licenses. Print a copy of your renewal license from our web site at www.insurance.pa.gov
[DOC File]PUC 181 (Revised 2/01) .us
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2. The signed original and one copy of the application must be filed with the Secretary, Pennsylvania Public Utility Commission, PO Box 3265, Harrisburg, PA 17105-3265. 3. A non-refundable filing fee of $350.00 is required at the time of filing. Applications without the required fee will be returned.
[DOC File]SjoMC-MSS-Practitioner Checklist for Initial Application ...
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- Certificate must include practitioner’s name, insurance company’s name and address, policy number, expiration date, and coverage amount (minimum $1 million/$3 million) in professional liability insurance coverage - Indicate on credentialing application if insurance is pending • Privilege Form(s)
[DOC File]Personal Care Section II - Arkansas
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240.000 prior authorization 1-1-19 A. The Arkansas Medicaid Personal Care Program requires prior authorization of services in the home and other locations for all beneficiaries, including beneficiaries participating in the IndependentChoices Program. B. Prior …
[DOC File]www.puc.pa.gov
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TRANSFER OF LICENSE: The Applicant understands that if it plans to transfer its license to another entity, it is required to request authority from the Commission for permission prior to transferring the license. See 66 Pa. C.S. Section 2809(D). Transferee will be required to file the appropriate licensing application. AGREED
[DOC File]Code - New Jersey
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inc. 333 earle ovington boulevard suite 505 uniondale ny 11553 comm only 174 paramount insurance company one park avenue new york ny 10016 comm only 175 insurance co of the state of pa 160 water st., 23rd fl new york ny 10038 comm and priv pass 176 acadia insurance company 4820 lake brook drive suite 300 glen allen va 23060-9233 comm only 177 ...
[DOCX File]COMMONWEALTH OF PENNSYLVANIA
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Commonwealth of Pennsylvania, this renewal addendum, and any necessary attachments. Include federal identification number (EIN) on your check and any attachments. o. r. RENEW ONLINE AT . WWW.SIRCON.COM. 8)We no longer mail licenses. Print a copy of your renewal license from our web site at www.insurance.pa.gov
[DOCX File]address change form - Pennsylvania
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please print name _____ date _____ (please advise insurance company of the above change of address) please return to: pennsylvania public utility commission. secretary’s bureau. 400 north street. harrisburg pa 17120. mc insurance fax: 717.787.3114
[DOC File]DRUG TESTING AUTHORIZATION & RELEASE
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drug testing authorization & consent form I, the undersigned, hereby knowingly and voluntarily authorize and consent to the collection and testing of specimens of my urine by a collection site and laboratory to be designated by Company or its designated agent, Employment Screening Services, Inc., for the purpose of drug testing.
[DOC File]address change form .us
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(please advise insurance company of the above change of address) please return to: pennsylvania public utility commission. secretary’s bureau. p.o. box 3265. harrisburg, pa 17105-3265. revised 10/2014
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