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.Ant~.eTn~~! <br />Mayfield Village <br />Proposed Effective Date; 04/01 /22007 Broker Names Lance & Co„ <br />Blue Aecess Option 1 $8/15!25 <br />Employee $ 429.94 $ - $ - $ 429,94 <br />Employee/Spouse $ 1,027.35 $ - $ - $ 1,027.35 <br />Employee/Child $ 789.22 $ - $ - $ 789.22 <br />Employee/Children $ 789.22 $ - $ - $ 789,22 <br />l~~unil $ 1,443.33 $ - $ - $ 1,443.33 <br />By sigiing this Race Authorization form, I agrcc to thc applicable rates and for the altuehed summtuy of bcnclfts scIcctcd as of thc <br />effective date indicated. <br />Authorized group signature ~ Uatc _ <br />7 <br />~ ' ~~ "1' <br />:~+ <br />CJndciwriting signature !)ate ~ ~ <br />Aml~,n 11miy1 ~i+~ye in urdw..+illm by AxrlFxm RloeCmbs and Aloe Shield, <br />Muni and Ywim wLruruenuinn rwinxpmviJul lsy F4altlr Mww~r an_rl Syuonti Ing. <br />And~cm Alm C.rnan anC ffiue9hiciJ is Ric Inule,wa,enfC wmmaily l.w,nnax: Glrnlw>,y. <br />An ir.lycixldu IioSe... ufll..•tllue Crwr„d Alne3hid! Aw..yuir,n. <br />CPRad#arzd myts tum cmss oa! Blun xtddd nssucLdloa <br />