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04/26/2004 SON 16;26 FAX 440 442 5077 MV BLDG DEPT <br /> <br />~] 004/004 <br />~ntkiem~ <br />Mayfield Village <br />Promised Effective Date: 4/1/2004 Broker Name: Lance & Co. /Ted Kravec <br />Slue Access NewBluc v02 - Option #1 $8/iS/25 rx <br />L~uployee $ 324.27 $ - $ - $ 324.27 <br />E>~p1oYCCISpouBe $ 775_i0 $ - $ _ $ 775.Io <br />Employoe/Chi1d $ 595.25 $ - $ - $ 595.25 <br />EmploYee/CIzildren $ 595,25 $ - $ - $ 395.25 <br />Fafuit ` $ !,088.59 $ - $ - $ I.USS_59 <br />MedicarelSing[e $ - $ .. $ _ $ _ <br />Medicare/Spouse $ _ $ _ $ _ $ <br />Medicare/Child $ $ _ 5 _ $ _ <br />MedicaxelCizkldren. $ _ $ _ $ _ $ _ <br />MCClIC~)C/F8111iL~- $ - $ _ $ _ ~ _ <br />By signing phis Rato Authorization form, I ageee to the applicable satc+s and for the a£tached summary of bcn~fits selected as of tl~e <br />°~~t;ve date indicated <br /> <br />IHIW G v~ <br />I IA+P <br />Anthem Dental coverage is underwritten by Anthem Blue Cross anal Blue Shield. <br />Aetttal and Vision administration services provided by wealth management Systems, Inc. <br />Anthem Blue Cross and Blue Shield is the trade name o~Comm~pn;ty Insurance Company, <br />An irtdepeztdettt licensee of the Blue Crass and. Blue Shield Association_ <br />®ltegistered marks Blue Cross and Blue Shield Association. <br />