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Mar•22. 2005 3:41PM <br />Nlayfield Village <br />Proposed Effcctivc Datc, 411/2005 Brokcr Nxmc: Lance & Co. <br />IIluc Access New f3lue v42 - Opt 1 $015$25 <br />No. 2340 P- 2 <br />*Vj?LAR Health, D <br />Employee $ 350.21 $ - $ - $ 350.21 <br />SmploycrlSpousc $ 837.11 S - $ - ? 837.11 <br />Employee/Child $ 642.87 $ - ? - s 642.87 <br />EmplayeelChildren $ 642.87 $ - $ - s 642,87 <br />I'amil p 1,175.68 $ - S - $ 1,175.68 <br />Medicare/Single s _ $ _ $ - $ - <br />Medicare/5pouse $ - $ - $ - $ - <br />Mcdicarc/Child $ - $ . S - $ - <br />Medic,areJChildren $ - $ - $ - $ - <br />Mcdicarc/Famil $ - $ - $ - S - <br />P.y signmg this Ratc Authorization form, l agree to ehe applicaUle rates and far tHe attacliec3 sumn,ary ofbeneGts selec;ted as af tlre effective &tc <br />indicatcd, <br />)t- <br />AwMm [Lw.l w`ro°Y f- ?M?r?•e ey M,h- rtw rnv„m nuu. mc.Ln <br />Rwul ad V'ucue eh..Lniewtiw Krrim wo•i&,lMt4diLMemy-i Sysiua, I. <br />AnNrn111Im (SOa oW Illee UJcI! 1R U. We nm d'C'-ilY t- f:o9+n1 <br />A. iwk{wnk.a lia-w -Me L+roe Gene.ro+nhw okv Newi-+i*? <br />MpOe:u,.a FW%e Am.CtDw em wn. mi.uf tiw owHnll <br />AutIiorized group <br />sibmulurc <br />/u`G.?%?/? ? <br />?iGlR? Date <br />/?????iG ?G ? c? <br />Undervrritiug s guature Dulc