Laserfiche WebLink
Mar.20. 2006 11:24AM <br />No, 8103 P- 2 <br />Anffiem,, ED. (W <br />May£ied Village <br />Proposed Effective Date- <br />4/1/2006 Broker Nacne: <br />Lance & Co <br />Bluc Access <br />New 131ue v02 - Option 1 <br />$S/15/25 rx <br /> <br />TYPE f <br />Bmployee s 387.33 ? - s - s 387.33 <br />Employce/Spousc $ 925.84 $ - $ - $ 925.84 <br />Employee/Cfiild $ 7I1.01 $ - $ - $ 711.01 <br />liniployee/Children $ 711.01 $ - $ - $ 711.01 <br />F3mil $ 1,300.30 S - $ - $ 1,300.30 <br />f3y signing this Rate Authorization fqrm., 1 agree ta the applicahle rates aiid for die attachcd summary of bcncfits sclcctcd as af thc <br />effective date indicated_ <br />i uthorized group signatu Datc y <br />U riling signaEurC `-` natz <br />NnIxm lleuicl vvtraRe t5 undtturtnm Dy MVxm LSNe Craas and Llfun MiafG. <br />Uenlal ard vyyon admimaraim Farviea Pmh4C4 ny I Icalie ma,uC,-i ww.ma. Ine <br />MIAcm lylly Crtw. ,r.4 rnkjn i. tp., ir,dn- nftr--iiy InM,r.n= i:-pxny <br />A. inJ??xknt lia.nwx nf a,, ALu: G,w uu3 Al- 4LiAlAwuicGuu. <br />QSQEOSiANN IOd[k.f 1S1U7 Gf0}c JIIO UI- M ?AIGId Auar.jallnp. <br />d <br />EXHIBIT A