Enrollment Form Clause Samples

Enrollment Form the electronic or paper agreement entered into between the Primary Member participating in the Plan accepted by the Plan Administrator.

Enrollment Form. A form provided by WHP to gather specific information about a Subscriber and his Dependents. Where appropriate, the form is to be signed by the Subscriber to show the Subscriber’s agreement to accept and comply with the terms of this Agreement.

Enrollment Form. By submitting the Enrollment Form, you certify that all of the information you provide in the Enrollment Form is true and correct, and you authorize us and our agents to verify the information in the Enrollment Form and seek or obtain information about you and your financial condition and history by use of consumer reports and other sources both now and in the future. Your Enrollment Form is subject to our review and approval.

Enrollment Form. The written or electronic form that each Eligible Employee must complete before he or she may participate in the Plan. To be effective, the Enrollment Form must include all of the information described in Section 3.01.

Enrollment Form. Each Full-Time Employee and each Part-Time Employee who, pursuant to Section 3.03 or Section 3.05 above, is required to become a Member, shall complete an enrollment form prescribed by the University and shall file such form with the University. Each Limited-Term Employee who, pursuant to Section 3.04 above, desires to become a Member, shall complete an enrollment form prescribed by the University and shall file such form with the University.

Enrollment Form. Upon request, Service Provider shall provide the Department with a Retail Voucher Program enrollment form. The enrollment form shall set forth the pricing, the time period the vouchers shall be available for redemption and other relevant Program details.

Enrollment Form. Attached hereto and incorporated by reference is the Enrollment Form, which, as amended or replaced from time to time, identifies Customer information, wire restrictions and additional terms and conditions.

Enrollment Form. This Agreement notifies (fill in contractor name here) of the provider’s consent to participate in Electronic Data Interchange (EDI). EDI may include claims and claims attachments, remittances, eligibility/benefits, claim status, and any other electronic information for Centers for Medicare and Medicaid Services (CMS) federal program data (including but not limited to Title XVIII of the Social Security Act (Medicare), and/or Section 1011 of the Medicare Modernization Act) covered under Health Insurance Portability and Accountability Act (HIPAA) Transactions and Code Sets or Section 1011 of the Medicare Modernization Act (MMA) legislation.

Enrollment Form. This Enrollment Form pertains to the Settlement Agreement (“the Agreement”) dated November ___, 2007, incorporated herein by reference, including but not limited to the program for resolution of claims relating to the use of Vioxx described therein (generally and collectively referred to herein as the “Resolution Program” or “the Program”). I, the undersigned, am submitting an updated version of the spreadsheet previously submitted by me initially for Registration of Claims pursuant to Section 1.1 of the Agreement, as may have been subsequently revised or updated in connection with the terms of the Agreement and the Registration Order (“Claimant Spreadsheet”). This updated Claimant Spreadsheet identifies, inter alia, (i) those claims for which I am the Primary Counsel; (ii) those Eligible Claimants for whom I hereby submit this Enrollment Form, as of the date indicated below; (iii) those claims listed in the Claimant Spreadsheet previously as Claims in which I have an Interest, but in which I or other affiliated counsel no longer have an Interest, including a certification whether any remuneration was received or promised in connection with disposition of any Interest in any such Claim; and (iv) claims not previously listed on my Claimant Spreadsheet in which I did not previously, but now do, have an Interest. I hereby certify that I have undertaken to verify the accuracy of the information contained in the spreadsheet, and that it is true and correct to the best of my knowledge and information. I hereby represent and certify that I, or another attorney in my office, have communicated with and explained the contents of the Agreement to the individuals on whose behalf I am submitting this Enrollment Form, and that I have full authority to submit this Enrollment Form on their behalf. I further represent that I have explained to those individuals that if their Enrollment Form is accepted under the terms of the Agreement: (1) participation in the Resolution Program subjects them to the authority of those persons specified in the Agreement, including, but not limited to, the Chief Administrator, the Special Master, and any Deputy Special Masters; (2) in connection with entry into the Program they are releasing their claims against the entities and individuals identified in the attached Release (Exhibit C), and that their Release may not be returned other than under the limited circumstances provided in Section 2.7 of the Agreement; (3) enrollment terminates any...