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Get Notice Of Proposed Terms Of Settlement

This is a fill and print form notice of proposed terms of settlement Pursuant to section 13 of the Health Care Costs Recovery Act Personal information on this form is collected under the authority of the Health Care Costs Recovery Act. The information will be used to identify recoverable health care costs as a result of a third party liability incident. If you have any questions about the collection of this information contact Third Party Liability s email at hlth. tpl gov*bc*ca or call 250 952-2034. Personal information is protected from unauthorized use and disclosure in accordance with the Health Care Costs Recovery Act and the Freedom of Information and Protection of Privacy Act. The payor s legal counsel may fill in and send this form on behalf of the payor PART A - BENEFICIARY Full Name of Beneficiary Date of Incident YYYY / MM / DD Date of Birth if known YYYY / MM / DD Personal Health CareCard Number if known PART B - PAYOR Full Name Address Postal Code Contact Phone Number include area code Email Address optional PART C Name and Address of Counsel if any Legal Counsel s phone number Name s of Potential Parties to Settlement Is this a Class Action Yes Has lawsuit been filed No Signature Date of Trial if known Registry Location Full Mailing Address Print Name Title of Signatory This form including attachments is sufficiently served if scanned and emailed to the following address hlth. tpl gov*bc*ca Date Signed YYYY / MM / DD Office Use Only OR Please send registered mail or traceable courier to Third Party Liability Ministry of Health Services 2-1 1515 Blanshard Street Victoria BC V8W 3C8 Please attach Proposed Settlement Terms Draft terms of settlement or Settlement Agreement Terms of proposed settlement must clearly outline the amount of the settlement applicable to health care costs And if applicable Releases Covenants not to sue HLTH 1495 2008/11/12 RESET. The information will be used to identify recoverable health care costs as a result of a third party liability incident. If you have any questions about the collection of this information contact Third Party Liability s email at hlth. If you have any questions about the collection of this information contact Third Party Liability s email at hlth. tpl gov*bc*ca or call 250 952-2034. Personal information is protected from unauthorized use and disclosure in accordance with the Health Care Costs Recovery Act and the Freedom of Information and Protection of Privacy Act. tpl gov*bc*ca or call 250 952-2034. Personal information is protected from unauthorized use and disclosure in accordance with the Health Care Costs Recovery Act and the Freedom of Information and Protection of Privacy Act. The payor s legal counsel may fill in and send this form on behalf of the payor PART A - BENEFICIARY Full Name of Beneficiary Date of Incident YYYY / MM / DD Date of Birth if known YYYY / MM / DD Personal Health CareCard Number if known PART B - PAYOR Full Name Address Postal Code Contact Phone Number include area code Email Address optional PART C Name and Address of Counsel if any Legal Counsel s phone number Name s of Potential Parties to Settlement Is this a Class Action Yes Has lawsuit been filed No Signature Date of Trial if known Registry Location Full Mailing Address Print Name Title of Signatory This form including attachments is sufficiently served if scanned and emailed to the following address hlth.

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