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Anthem. ~•~. <br />Mayfield Village <br />Proposed Effective Date: 04/01/2008 Broker Name: Lance & Co. <br />Blue Access 3.0 Option 1 $10/20/30 rx <br />Employee $ 481.53 $ - $ - $ 481.53 <br />Employee/Spouse $ 1,150.63 $ - $ - $ 1,150.63 <br />Employee/Child $ 883.93 $ - $ - $ 883.93 <br />Employee/Children $ 883.93 $ - $ - $ 883.93 <br />Famil $ 1,616.53 $ - $ - $ 1,616.53 <br />By signing this Rate Authorization form, I agree to the applicable rates and for the attached summary of benefits selected as of the <br />effective date indicated. <br />Authorized group signature Date <br />Underwriting signature Date <br />Mllmn DmW cwmge i. uodm+iaen by Mllcm Blue Cra. wd Blue Shield. <br />DrnW ..d Vision Wmininnum.en+m. proridad by Halih M.n.panrn~ sy.um.., lm <br />Mdum Bluc C.o...nd Hlue Shield i. Ur trade mm~e ofCanmuairy In.m.nm Cavpevy <br />M udcpcndnu lioemm afde Bhe Cron end Bhe Shicd A..mi.tim <br />~Rcgi.lmcd muk. Blue Cron vd Blue Shield A..eeulim <br />